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advocacy and commentary with a focus on Lane County, Oregon

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Stepping Toward A Baby-Friendlier Oregon

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The Breastfeeding Coalition of Oregon under the direction of Amelia Psmythe recently hosted its sold-out 5th annual two-day statewide conference – Stepping Toward A Baby-Friendlier Oregon. Supporters who made the conference possible include Oregon WIC, Oregon Public Health Institute, Hygeia, Limerick, and Medical International.

Anyone wanting to know what Oregon’s many infant-feeding stakeholder groups are up to should make a habit of attending. While there is still so much to be done to protect and promote breastfeeding, the following downloadable synopsis of conference presentations will give you a quick bird’s eye view of the excellent and diverse work already underway.

Oregon is fortunate to have an extraordinarily talented cadre of savvy, skilled and committed advocates for quality care. Throughout the state, these advocates promote and protect women’s health, well being and basic human rights spanning the entire arc of their reproductive lives whether at home, in the community, in the health care system, in the economy or as “subjects” of scientific research and inquiry. The BCO annual conference is a good opportunity to check in and rally for the difficult but critical work ahead to achieve breastfeeding’s full-spectrum benefits for the entire population.

Framing the discussion…Presentations and discussion were conceived of and organized to align with the Surgeon General’s Call to Action to Support Breastfeeding (SGCTA). The SGCTA is a federal tool to direct policy, fund activities and align stakeholders around important objectives outlined in Healthy People 2020. Federal, state and local grants and staffing resources are made available and prioritized based on alignment with SGCTA objectives.

The SGCTA to Support Breastfeeding is a ground-breaking document because it is a clear departure  from previous policy and political frameworks that define breastfeeding as an individual responsibility or lifestyle choice beyond the concern, responsibility and reach of government focus. Finally, breastfeeding behaviors and outcomes have been re-defined as the product of cultural norms and structures at all levels of society. Accordingly, public health workers, researchers, employers, health care systems, communities and families are “called to action” to better and more effectively support mothers and babies to breastfeed.

Presentation Synopses. Following is a list of presentations. It gives a wide-angle view of how individuals and institutions are aligning Oregon with the SGCTA. Click here for a version of this post that also includes a synopsis of each presentation.

The Role of Consumer Advocacy in Increasing E-B Infant Feeding Practices
Katharine Gallagher, MPP. Consumer advocate, blogger and independent childbirth educator.
slides
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Let’s Talk! Breastfeeding Education Series Tear Sheet Project
Rachel Martinez, BA, IBCLC, RLC. New Member Training Coordinator at Nursing Mothers Counsel of Oregon, and Legacy Emmanuel Hospital lactation consultant.

The Oregon Black Women’s Birth Survey
Shafia Monroe, Midwife. Founder of the International Center for Traditional Childbearing

Supporting Families the Whole Way: Continuity Care Model
Debbie Alba, RN, IBCLC. Nurse and Lactation Consultant at Good Samaritan Regional Medical Center, currently serving as Western Region Steering Committee Chair

Angie Chisholm, CNM. Certified Nurse Midwife at Samaritan OB/GYN in Corvallis, with a long interest in lactation and evidence-based care.

Oregon WIC Peer Counseling: A Public Health Approach
Kelly Sibley, MPH, RD, IBCLC. Nutrition Consultant and Breastfeeding Coordinator with the Oregon State WIC Program. Coordinates WIC BF peer counselors.

Engaging Community Partners in Breastfeeding Support
Helen Bellanca, MD, MPH. Family physician who has worked with health policy and advocacy for four years, leading insurance collaborative and child care survey.

Lessons Learned on the Way to Baby-Friendly: Providence Newberg
Joanne Ransom, RN, IBCLC. Labor & delivery nurse and lactation consultant at Providence Newberg, former Vice-Chair of Northwest Mothers Milk Bank, new OEBIN co-lead

Redesignation with Baby-Friendly: Strategies for Success
Michelle Stevenson, RN. Perinatal Nurse and former La Leche League Leader, led two CA hospitals to Baby-Friendly designation, and now manages the Women and Newborn Care and Nursery at Kaiser Sunnyside Hospital.

Eliminating Elective Deliveries Prior to 39 Weeks Gestation: OR Challenge
Joanne Rogovoy, Executive Director of the Oregon March of Dimes, and leader of the workgroup that banned early c-sections on Portland area hospitals.

Donor human milk & Northwest Mothers Milk Bank
June Winfield, Board Chair / Director

Breaks for Nursing Mothers are Federally “Reasonable”
Amelia Psmythe, Director of the Breastfeeding Coalition of Oregon and West Region Coalition Representative to the United States Breastfeeding Committee.

Nursing Mothers Counsel Workplace Lactation Support Program
Marion Rice, Ed.D. 25 year educator, currently leads the Nursing Mothers Counsel of Oregon Worksite Lactation Support Program

What Do Women Really Want? A 21st Century Mother’s Movement
Andrea Paluso, MSW, MPH. Co-founder of Family Forward Oregon, The Mother PAC, and recent graduate of the Emerge Oregon legislative mentoring program.

Breastfeeding Outcomes in Women with a Prior History of Cesarean Section
Cathy Emeis, PhD, CNM. A nurse-midwife and researcher at OHSU, Cathy’s current research examines the impact of birth interventions and c-section on breastfeeding.

Breastfeeding Coalition of Oregon: Northwest Edge of the Wave of Change
Amelia Psmythe, Director of the Breastfeeding Coalition of Oregon and West Region Coalition Representative to the United States Breastfeeding Committee

US Breastfeeding Committee Annual Report
Robin Stanton, MA, RD, LD. USBC Past-Chair and Nutrition Consultant with OR Department of Human Services, Public Health Division

Collaboration for Collective Impact
Amelia Psmythe and Robin Stanton, MA, RD, LD

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Part 2: Consumer Advocacy & Evidence-Based Infant Feeding Practices

Here’s the second “installment” for my upcoming presentation at the March 2-3 Breastfeeding Coalition of Oregon’s 5h Annual Meeting. Blue text indicates information that will be placed on PowerPoint slides, black text indicates what will be said. I’d love your feedback either here or via email at motherbabynetwork@gmail.com. Read the first installment

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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Will Oregon hospitals close the breastfeeding care gap?

Evidence-based infant feeding care is the future for hospitals in the United States. Oregon is at a critical juncture: will it lead by building on the unique, forward-thinking approach for which it is known? Or, will it wait for other regions or states to lead? Waiting might make sense for some states but not for Oregon – the home of several cutting-edge leaders, thinkers and organizations where infant feeding is concerned.

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.

 

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Project Aims to Improve OR Hospital-Based Breastfeeding Services

With funding support from Oregon WIC and Multnomah County Health Department, the Breastfeeding Coalition of Oregon (BCO) recently launched a new statewide project – Oregon Hospitals Partnering for Evidence-Based Infant Nutrition. This project supports hospitals in developing the evidence-based systems associated with increased rates of breastfeeding.  The project aims to promote evidence-based hospital maternity practices related to breastfeeding by offering technical assistance, convening a spring 2011 hospital summit, and supporting the formation of a hospital collaborative learning community.

Lane County’s Desiree Nelson joins the project’s four-member team:  BCO Director Amelia Psmythe, Helen Bellanca, MD, MPH, Rachel Burdon, RN, MPH, and Mary Lou Hennrich, RN and Executive Director of Oregon Public Health Institute (OPHI).  Oregon WIC allocated federal funds for increasing breastfeeding rates through outreach to hospitals. Locally, Nelson is well known for co-founding Baby Connection, a phenomenally successful live demonstration of Baby Friendly step 10:

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

Arriving early and leaving well after closing time, families and babies consistently demonstrate the very real but unmet demand for weekly, drop-in evidence-based lactation support in the weeks and months following birth.

Key Backers

The BCO’s parent organization, the Oregon Public Health Institute recently formed an innovative working group for health insurers – the Oregon Health Insurers Partnering for Prevention (OHIPP). The first of its kind in the nation, OHIPP is a collaborative obesity prevention effort between health plans and public health policy advocates.

Currently, six health insurers participate in OHIPP – representing 65% of private insurance and 45% of Medicaid. Insurers contribute money to fund selected interventions. Because breastfeeding is increasingly associated with reduced risk of childhood obesity, OHIPP has selected increasing breastfeeding rates as its first collaborative public health intervention.

OHIPP’s direction could have a huge impact on breastfeeding practices in Oregon. Imagine, for example, the impact of a reimbursement system in which rates for births were higher for hospitals certified as evidence based by the Baby Friendly Hospital Initiative. This type of innovative intervention conveys the importance of becoming evidence based and signals growing understanding that evidence-based care is preventive and effective in the long run.  In this scenario, hospitals would be incentivized to seek support and resources like those the BCO is offering through this project.

Additional critical support for evidence-based breastfeeding services comes from the Oregon Association of Hospitals and Health Systems (OAHHS). A recent OAHHS membership survey indicates 85% of nurse managers are aware of the gold standard for evidence-based breastfeeding support systems – the Baby Friendly Hospital Initiative. 39% want technical assistance and support on Baby-Friendly 10 Steps. Plans are underway for OAHHS to partner with the BCO to co-brand educational opportunities and communicate the importance of evidence-based breastfeeding support to its membership.

Hospital Outreach

The Oregon Hospitals Partnering for Evidence-Based Infant Nutrition project is in the initial outreach phase to hospitals and health system leaders. Interested hospitals are encouraged to begin forming multi-disciplinary teams for the purpose of assessing current internal practice. Representatives from these teams will be invited to participate in a Spring 2011 summit for a day of education, group facilitation and collaboration. Participants will be encouraged to form an ongoing network of communication between their facilities, to support the path toward institutional change.  Interested hospitals should contact Amelia@breastfeedingOR.org or Desiree@breastfeedingOR.org for more information.

Lane County’s PeaceHealth Nurse Midwifery Birth Center is one of four Baby Friendly Hosptial Initiative-designated facilities in Oregon. Community and consumer support for moving the birth center from downtown Eugene to the new Sacred Heart Medical Center campus in Springfield were centrally linked to the unwavering demand for ongoing access to evidence-based breastfeeding services. Judging by the outcomes and immense demand for these services, making them available at the county’s two leading hospitals, Sacred Heart Medical Center (SHMC) and McKenzie-Willamette Medical Center would be a tremendous boon for families and communities.

Next week, Lane County Friends of the Birth Center will release results from a recent survey taken by more than 100 local women and families describing their experiences evidence-based breastfeeding services at the PeaceHealth Nurse Midwifery Birth Center. Demonstrating the connection between evidence-based services and consumer satisfaction, LaneCoFBC intends the survey to encourage all Lane County hospitals to achieve the Baby Friendly designation. For a copy of the survey, email lanecofbc@gmail.com. (Click here to access the survey.)

Progress already

Locally, there is positive discussion of SHMC RiverBend Labor and Delivery staff’s recent innovative and successful introduction of uninterrupted skin-to-skin contact immediately following birth. Providing skin-to-skin as standard care is a very positive development because it is bedrock practice for developing evidence-based breastfeeding services. Babies placed skin-to-skin with their mother are more likely to be breastfed and to breastfeed for longer.

Having SHMC Labor and Delivery staff describe how front-line practices and internal systems have been altered to bring more evidence-based care to the floor is an example of useful information that could be shared at the upcoming Spring 2011 summit hosted by the Oregon Hospitals Partnering for Evidence-Based Infant Nutrition project. Attending health professionals would return to their respective hospitals with a concrete, doable action for improving mother-baby breastfeeding outcomes.

Writing on the wall

Discussion of evidence-based breastfeeding care is a roundabout way of saying hospitals should identify ways to understand and implement Baby-Friendly practices. Savvy hospitals understand consumers, legislators, government agencies, the business community and accreditation bodies have connected hospital-based breastfeeding practices with the success mothers and babies have in the months following discharge.

Perusal of the following links demonstrates a trend toward adoption of Baby Friendly language for discussions of evidence-based care. They also demonstrate large-scale convergence around breastfeeding as a top-ranking major objective in health care.

  • The Joint Commission’s new perinatal care core measure set includes exclusive breast milk feeding

The question hospitals must answer about breastfeeding services is no long whether or not to become evidence based but (1) how to do it and (2) how to demonstrate that it is being done. Because Baby-Friendly is the established and universal standard for effective breastfeeding care, pursuing and maintaining this designation answers both questions in the most expedient manner. The project’s greatest potential value to hospitals lies in the efficiencies it can generate through developing models of collaboration for identifying and removing barriers to reform. The potential for idea sharing and cost sharing for staff training and education increases significantly with each hospital’s commitment to participate.

To learn more, contact Amelia@breastfeedingOR.org or Desiree@breastfeedingOR.org for more information.

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Better Breastfeeding Services in the context of CEOs, Grandmas and Formula

On Monday, I attended and participated in a panel discussion at the Moving Communities Toward Evidence Based Breastfeeding at St. Charles Hospital in Bend. The conference was the result of a productive collaboration between Oregon WIC, the Central Oregon Breastfeeding Coalition and St. Charles. Dr. Marianne Neifert was the conference speaker.

Moving Communities Toward Evidence Based Breastfeeding reflects growing awareness among consumers, healthcare providers and government agencies of the need to implement breastfeeding practices inside hospitals that effectively support women and infants to initiate breastfeeding. Ineffective practices including failure to assess proper latch, formula supplementation and inadequate follow up after birth undermine the long-term prospects for women and infants to establish an adequate milk supply. In other word, the days of “you can breastfeed when you go home” must end.

Kudos to Desiree Nelson, WIC Project Coordinator for the Improvement of Maternity Care Practices, for organizing the conference and to St. Charles for making it possible by hosting. I had hoped this conference would be held in the Eugene/Springfield areas as there is considerable buzz “on the street” that Sacred Heart Medical Center is seriously considering becoming a designated Baby-Friendly facility.

The panel discussion in which I participated included consumers (myself and another woman from Bend), doctors, a hospital administrator and a WIC employee. The composition of the panel modeled the kind of stakeholders conversation needed throughout the state to encourage the adoption of sound breastfeeding practices. (Many thanks for including consumers in the discussion.) As consumers, we described the long-term effects receiving non-evidence based care had on initiating breastfeeding. We described the enormous difficulties of accessing lactation expertise inside and outside the hospital as well as the difficulties of being encouraged repeatedly to formula feed despite making the preference for breast milk known. Like so many other women, our expectations for breastfeeding support were not matched by the services provided.

Three great terms

Three particularly descriptive terms were used during the conference. They describe the difficulties proponents for better mother- and baby-care must contend.

CEO Hurdles. These hurdles refer to business concerns that can conflict with optimal health care for women and babies. For example, designated Baby-Friendly hospitals do not accept free formula. Convincing management that this is not only the correct decision but also one that will not compromise market share is, to put it mildly, challenging. Perhaps as increasingly savvy consumers and government agencies come to see and describe free formula as cheap swag, this hurdle can be cleared.

Block Party. This refers to the trend toward having large numbers of family and friends in the delivery room who are unfamiliar with how breastfeeding is most well supported. In the absence of this information, the clamors to see and hold a new baby frequently trump mother and baby skin-to-skin contact. Nurses and lactation specialists commented on how hard it is for them to protect the mother-baby window for bonding. In the absence of prenatal education about the role of  skin-to-skin contact for breastfeeding, nurses have a hard time diplomatically helping make this happen. After all, who’s going to tell grandma she can’t hold the baby just yet?

Mamatoto. This is a Swahili word for the mother-baby unit. Keeping mothers and infants together is the best way to encourage a good start for breastfeeding. We don’t have this word in English but we need one. My answer is to make it happen by putting “mother” and “baby” together to make “motherbaby.”

Moving Forward from the Middle

Moving Communities’ strength was in its devotion to equipping participants with the knowledge and encouragement to move their respective organizations toward sound breastfeeding practices even in as they contend with CEO hurdles on one end and grandmas who likely did not breastfeed and have yet to have a chance to learn how to be supportive at the other end. It’s a tall order.

Dr. Neifert spent a great deal of time describing the development and implementation of Colorado’s Can Do 5 program. This program serves as a useful tool for moving healthcare facilities and providers toward evidence based breastfeeding practices. Can Do 5 is useful because:

  • It’s an intermediate subset of steps on the way to becoming Baby-Friendly. (Many administrators and staff see Baby-Friendly designation as a daunting starting objective, especially in light of CEO hurdles.)
  • It represents incremental changes fundamental to positively promoting long-term breastfeeding success for families.
  • It generates momentum among management and staff as positive outcomes and familiarity with new practices increase. With these steps accomplished, it is much easier to take the additional Baby-Friendly step of refusing free formula from manufacturers.

So, what is Colorado’s Can Do 5?

The “Can Do 5” program is the result of analyzed data from the 2002 and 2003 Colorado PRAMS surveys having been presented to hospital staffs and administrators. The PRAMS survey is a population-based surveillance system for identifying and monitoring behaviors and experiences of women before, during and after pregnancy. Questions regarding hospital breastfeeding practices were added in 2002. These “yes” or “no” questions roughly mirrored the Baby-Friendly Ten Steps:

  1. Hospital staff gave me information about breastfeeding
  2. My baby stayed in the same room with me at the hospital
  3. I breastfed my baby in the hospital
  4. I breastfed my baby in the first hour after my baby was born
  5. Hospital staff helped me learn how to breastfeed
  6. My baby was fed only breast milk in the hospital
  7. Hospital staff told me to breastfeed whenever my baby wanted
  8. The hospital gave me a gift pack with formula
  9. The hospital gave me a telephone number to call for help with breastfeeding
  10. My baby used a pacifier in the hospital

The survey response rate was at least 70% each year and results were weighted accurately to reflect all Colorado mothers.

Survey says….

Colorado found that five specific hospital practices were significantly associated with longer durations of breastfeeding:

  • Baby breastfed in first hour (72%)
  • Baby stayed in mother’s room (93%)
  • Baby fed only breast milk (46%)
  • No pacifier use in hospital (46%)
  • Given phone number to call for help (84%)

The average number of practices reported was 2.8 and less than half of babies left the hospital without being supplemented or given a pacifier. Just one in five mothers reported experiencing all five of these supportive practices. But what a difference this made for these mothers and babies! Two-thirds  (68%) of this group were still breastfeeding at 16 weeks, compared with half (53%) of those who did not get all five practices. Of particular interest? Breastfeeding rates for this group were consistently higher for women below, at and above the poverty level – EVERYONE benefited.

2 months (wk 9) 4 months (wk 17)
All mothers yes = 80%, no = 64% yes = 63%, no = 48%
Medicaid yes = 66%, no = 47% yes = 47%, no = 35%
High Socioeconomic Status yes = 90%, no = 78% yes = 78%, no = 61%

Yes = got all 5 practices

No = did not get all 5 practices

See the 2007 published findings at www.cdphe.state.co.us/ps/mch/gettingitright.pdf

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Formula Company lobbyists hard at work

In response to today’s Washington Post article, Lobbying fight over infant formula highlights budget gridlock, I sent the following letter to the editor:

Thank you for bringing to light the latest scam perpetrated by formula companies against the country’s most vulnerable women and children. Under the aegis of improved efficacy, they seek to force more expensive formula on WIC in the absence of any evidence of increased benefit for babies.

That formula companies and their lobbyists try to block efforts for FDA due diligence by suggesting it is racism or the work or ideological “lactivists” would be funny, if only it weren’t so effective.

There is good news. Some state WIC programs, including that of my home state of Oregon, are daring to meet their clients’ needs and honor their rights. How? By recognizing the impossible barriers to informed feeding choices that they face before they ever make it to WIC. Most hospitals’ infant feeding practices guide women to formula before they go home. You’re right – it’s not about breastfeeding, it’s about profit.

Here’s hoping Oregon WIC and other state WIC programs will continue demanding the level of care all families deserve. Let’s hope elected officials and lobbyists promote rather than quash a move to bolster mother- and infant-health.