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Jill A. Gutmann
Capstone Project
ii
Acknowledgements
I would like to acknowledge:
Dr. Mase for his endless hours of effort and support through the process of completing this
work.
My daughter Daria Ziva, who traveled with me along the journey towards earning my Masters in
Public Health. Whether it was attending a class, going to a conference, or writing a paper; Daria
was always by my side. Daria makes me love nursing and inspires me to share and make
assessable the joys and pleasures of it with all mothers!
My fabulous husband, Brent. His support and encouragement as a breastfeeding advocate and as
a supporter of my work, allowed me to complete this project and my degree.
My mother and grandmother Minnette for all of their time, energy, and support watching Daria
while I was trying to complete this project.
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Abstract:
Objectives: This research provides generalizable knowledge as to whether the Baby Friendly
Hospital Initiative (BFHI), a global initiative aimed at improving maternity services to best
enable mothers to successfully breastfeed babies, is a possibility for Ohio hospitals to initiate in
order to improve breastfeeding rates in Ohio to meet the Surgeon General’s “2011 Call to
Action” and the Healthy People 2020 goals.
Methods: Following a literature review and policy analysis, the researcher conducted three semi-
structured, hour-long telephone interviews with lactation staff representing all four hospitals in
Ohio with BFHI designation.
Results: After receiving Baby-Friendly designation each of the hospitals saw increases in
lactation initiation. All participants felt positively about the BFHI and the process of obtaining
designation. Key findings are discussed in a theme analysis.
Conclusions: The Baby-Friendly Hospital Initiative is a path towards providing optimal care for
newborns and mothers to support, promote, and protect breastfeeding. BFHI could be expanded
in Ohio hospitals to increase lactation rates, increase lactation support, and promote
breastfeeding.
Keywords: Ohio, Lactation, Breastfeeding, Baby-Friendly Hospital Initiative
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Table of Contents:
Part 1: Introduction- Pages 1-12
Part 2: Methods- Pages 12- 14
Part 3: General Observations and Theme Analysis- Pages 14- 32
General Observations- Pages 14- 19
Theme 1: Policy- Pages 19-21
Theme 2: Hospital Personnel- Pages 21-29
Theme 3: Patient Education- Pages 29-32
Part 4: Discussion- Pages 32-35
Limitations and Recommendations for Future Research- Pages 35-36
Part 5: Conclusion- Pages 35-37
Work's Cited- Pages 38-40
Appendices- Pages 41-43
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Part 1: Introduction:
Breast milk is the best and most ideal food for human babies. Babies benefit in
numerous ways from breast milk and mothers benefit in numerous ways from nursing. Breastfed
babies experience lower rates of many illnesses such as: urinary and respiratory infections,
diarrhea, and bacterial meningitis. So too, benefits to mothers of nursing and pumping include:
reduced risk of breast and ovarian cancer, and nursing helps moms lose weight postpartum (“101
Reasons to Breastfeed”, 2011). The following chart from "the Surgeon General's Call to Action
to Support Breastfeeding, 2011" highlights several of the excess health risks faced by mothers
and babies that do not nurse (U.S. Department of Health and Human Services, 2011).
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In addition to improving health amongst babies and mothers, breastfeeding also reduces
medical costs and is better for the environment. It is estimated that $13 billion a year in health
care costs could be saved if all American babies breastfed. Additionally, research demonstrates
that mothers who breastfeed are more productive since they miss work less often to care for their
sick infants, and employer medical costs are less impacted by the cost of medical care.
Breastfeeding is also better for the environment than formula feeding because it produces less
waste in the form of formula containers (“Why Breastfeeding is Important”, 2011). "The
Surgeon General's Call to Action to Support Breastfeeding, 2011" found:
Increasing rates of breastfeeding can help reduce the prevalence of various illnesses and
health conditions, which in turn results in lower health care costs. A study conducted in
2001 on the economic impact of breastfeeding for three illnesses—otitis media,
gastroenteritis, and NEC—found that increasing the proportion of children who were
breastfed in 2000 to the targets established in Healthy People 2010 would have saved an
estimated $3.6 billion annually. These savings were based on direct costs (e.g., costs for
formula as well as physician, hospital, clinic, laboratory, and procedural fees) and
indirect costs (e.g., wages parents lose while caring for an ill child), as well as the
estimated cost of premature death. A more recent study that used costs adjusted to 2007
dollars and evaluated costs associated with additional illnesses and diseases (sudden
infant death syndrome, hospitalization for lower respiratory tract infection in infancy,
atopic dermatitis, childhood leukemia, childhood obesity, childhood asthma, and type 1
diabetes mellitus) found that if 90 percent of U.S. families followed guidelines to
breastfeed exclusively for six months, the United States would save $13 billion annually
from reduced direct medical and indirect costs and the cost of premature death. If 80
percent of U.S. families complied, $10.5 billion per year would be saved (U.S.
Department of Health and Human Services, 2011).
With such a prevalence of formula feeding today, it is important to understand how
formula came to compete with breastfeeding. Although breastfeeding is the natural way to
nourish a human baby, during the late nineteenth century and throughout the twentieth century
alternatives to human milk substitutes developed. In the early years of the twentieth century,
sanitation and preservation technology developed significantly (the home icebox, preservatives,
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etc.), which improved dairying practices and milk handling. At the turn of the twentieth century,
most infant formulas were made at home where they could be stored in the home icebox. The
early formulas were not vitamin fortified. In the 1920’s, orange juice and cod liver oil were given
to infants along with the formula to combat survey and rickets. The largest decline in
breastfeeding occurred from 1930 through the 1960s due to the increased availability of
commercially prepared formulas and a concomitant increase in iron deficiency among infants.
Iron fortified formulas were introduced during this period. At the same time, cow’s milk and
beikost were introduced into the diet at earlier ages. Eventually, few infants were breastfed or
formula fed after four to six months of age (Fomon, 2001).
Increased availability of commercially prepared formulas caused home-prepared
formulas to decline as well. From 1970 through the end of the century, there was a resurgence of
breastfeeding and a prolongation of formula feeding with the increase in usage of iron-fortified
formulas. Beginning at the end of the twentieth century, formula feeding and breastfeeding older
infants supplanted the use of fresh cow’s milk and the prevalence of iron deficiency of formula
fed infants has decreased (Fomon, 2001).
In the United States, formula companies heavily market their products to new mothers
through formula giveaways at physician offices and birthing hospitals, and through aggressive
advertizing. An October 15th, 2012 article in the New York Times entitled, "Hospitals Ditch
Formula Samples to Promote Breast-feeding" suggests, "The C.D.C., the World Health
Organization, and breast-feeding advocates say samples turn hospitals into formula sales agents
and imply that hospitals think formula is as healthy as breast-feeding." The article continues,
"They say that while some women face serious breast-feeding challenges, more could nurse
longer with greater support, and that formula samples can weaken that support system
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(Belluck)." The United States has not adopted the International Code of Marketing of Breastmilk
Substitutes. The Code is a health policy framework used internationally that was adopted by the
World Health Organization (WHO) and the World Health Assembly (WHA) in 1981.
Developed in the early 1980’s, the purpose of this code was to promote a public health strategy
that recommends restrictions on the marketing of breastmilk substitutes to ensure that mothers
are not discouraged from breastfeeding as a result of aggressive marketing (“International Code
of Marketing Breast-Milk Substitutes”, 1981).
The number of women breastfeeding in the United States has been increasing consistently
since the early 1990’s, although recently these gains have begun to level-off. In 2011, 74.6% of
US women initiated breastfeeding, 44.3% of US women breastfeeding at six months, and 23.8%
of US women breastfed for one year (“Breastfeeding Report Card- 2011", 2011 ). The “Healthy
People 2020” goals are for 81.9% of women to initiate breastfeeding, 60.6% of women to
breastfeed for six months, and 34.1% of women to breastfeed for one year (“Maternal, Infant,
and Child Health- Healthy People”). The current rates fall far short of these goals, especially at
the six month and one year levels.
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Because of all the benefits to babies, mothers, the environment and society, encouraging
breastfeeding is a national public health goal. In 2000, the US Surgeon General said, “The
nation must address these low breastfeeding rates as a public health challenge and put into place
national, culturally appropriate strategies to promote breastfeeding (Grummer-Strawn and
Shealy, 2009).” This issue continues to be at the forefront of the Surgeon General’s agenda. In
January 2011, the Surgeon General stated in their “Call to Action”:
One of the most highly effective preventive measures a mother can take to protect the
health of her infant and herself is to breastfeed. However, in the U.S., while 75 percent of
mothers start out breastfeeding, only 13 percent of babies are exclusively breastfed at the
end of six months. Additionally, rates are significantly lower for African-American
infants.
The decision to breastfeed is a personal one, and a mother should not be made to feel
guilty if she cannot or chooses not to breastfeed. The success rate among mothers who
want to breastfeed can be greatly improved through active support from their families,
friends, communities, clinicians, health care leaders, employers and policymakers.
Given the importance of breastfeeding for the health and well-being of mothers and
children, it is critical that we take action across the country to support breastfeeding.
(U.S. Department of Health and Human Services, 2011)
The January 2011 “Call to Action” was a milestone for breastfeeding advocates in the
United States and drew attention to the importance of removing the barriers that prevent women
from reaching their breastfeeding goals. It also served as an important voice to encourage all
participants in the US health care system to promote breastfeeding (Saadeh, 2012).
Certain cross-sections of the population exhibit greater success initiating and sustaining
breastfeeding. More specifically, studies show the following demographics are most likely to
initiate and sustain breastfeeding: those who are white, older, married, have received some
higher education, and are better off financially. Social influences including, support from the
infant’s father, family, friends, nurses and physicians, can also have a positive effect on
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breastfeeding initiation and duration. Other key factors that affect breastfeeding initiation and
sustaining breastfeeding for all races are the need to return to work, beliefs about breastfeeding
and knowledge of the benefits of breastfeeding (Lewallen and Street, 2010). The study by
Lewallen and Street (2010) suggested that, “A less well studied factor that may also affect the
breastfeeding practices of African American women is culture.” Lewallen and Street argue that
there may be cultural norms in place that make it challenging for African American women to
initiate and continue nursing such as perceptions that formula feeding is better, discomfort with
nursing publicly, and inadequate support from family and peers as to the benefits of nursing.
In the United States, there are different geographic norms that also affect breastfeeding
initiation and duration. The state of Ohio is one of the lowest performing states, 44th out of 50
for having ever breastfed. According to the CDC's Breastfeeding Report Card-2012, only 62.3%
of Ohioans ever breastfed, 39.5% were breastfeeding at six months, and only 25.6% breastfed for
at least twelve months. States in the Midwest and South tend to have similar rates to Ohio
("Breastfeeding Report Card—United States, 2012", 2012).
The Centers for Disease Control and Prevention 2011 Breastfeeding report card suggests,
Birth facility policies and practices significantly impact whether a woman chooses to start
breastfeeding and how long she continues to breastfeed. Several specific policies and
practices, in combination, determine how much overall support for breastfeeding a
woman birthing in a given facility is likely to receive and how likely her baby is to
receive formula in the first 2 days.
There are two initiatives, one national and one global, which provide informative
measures of birth facility support. The national initiative is the mPINC Survey initiated by the
CDC, in collaboration with the Battelle Centers for Public Health Research and Evaluation in
2007. The mPINC survey measures breastfeeding-related maternity care practices at
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intrapartum care facilities across the U.S. and compares the extent to which these practices vary
by state. The state mPINC score represents the extent to which each state's birth facilities
provide maternity care that supports breastfeeding (“Breastfeeding Report Card- 2011”, 2011).
The global initiative is called the Baby-Friendly Hospital Initiative (BFHI). BFHI is an
international program established in 1991 and revised in 2006. It is sponsored by the World
Health Organization (WHO) and the United Nations Children's Fund (UNICEF) to encourage
and recognize hospitals and birthing centers that offer an optimal level of care for lactation
based on the WHO/UNICEF Ten Steps to Successful Breastfeeding for Hospitals
(“Breastfeeding Report Card- 2011”, 2011). “The BFHI assists hospitals in giving mothers the
information, confidence, and skills needed to successfully initiate and continue breastfeeding
their babies or feeding formula safely, and gives special recognition to hospitals that have done
so.” There are more than 19,000 hospitals around the world that have BFHI designation.
However, there are only 143 in the United States as of May, 2012. Four of the 143 facilities
with Baby-Friendly designation are located in the state of Ohio ("Baby-Friendly Hospital
Initiative", 2012).
In order to be designated as "Baby-Friendly," facilities undergo external evaluation and
must demonstrate that the facility meets all of the Ten Steps requirements.
1. Maintain a written breastfeeding policy that is routinely communicated to all health
care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within one hour of birth.
5. Show mothers how to breastfeed and how to maintain lactation, even if they are
separated from their infants.
6. Give infants no food or drink other than breastmilk, unless medically indicated.
7. Practice “rooming in”-- allow mothers and infants to remain together 24 hours a day.
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8. Encourage unrestricted breastfeeding.
9. Give no pacifiers or artificial nipples to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on
discharge from the hospital or clinic
The "Baby-Friendly" designation can be sought by all types and sizes of birth facilities. In the
United States, there is great variety in the institutions that have received "Baby-Friendly"
designation. In some states, there are several small "Baby-Friendly" facilities; in other states
there are only one or two large ones; yet, still other states have none at all (“Breastfeeding Report
Card-2011”, 2011). The Centers for Disease Control and Prevention recommends in the 2011
Breastfeeding Report Card, “Because facilities vary in size and the number of births, measuring
their impact on public health requires more than just counting the number of "Baby-Friendly"
facilities per state. The best way to measure their impact is to look at the proportion of births in
a given state occurring at facilities that have earned the "Baby-Friendly" distinction.” In 2011,
only 4.1% of births in the state of Ohio were at "Baby-Friendly" facilities (“Breastfeeding Report
Card-2011”, 2011).
The number of institutions with “Baby-Friendly” designation in the United States has
continued to grow, but is still under ten percent of all US Birthing facilities. With the “Call to
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Action” and the CDC annual breastfeeding report cards, BFHI is on the radar of politicians,
policy analysts, politicians and hospital administrators. In April of 2012 , Mayor Bloomberg
announced that the New York City (NYC) Health Department would launch an initiative to
encourage city hospitals to obtain “Baby-Friendly” designation. The health department of NYC
is asking maternity hospitals to voluntarily limit the promotion of infant formula because it can
interfere with breastfeeding. The state of Illinois is also promoting the BFHI. On June 28,
2012, Illinois Governor Pat Quinn signed House Bill 4968. The bill calls on every hospital that
provides birthing services to “adopt an infant feeding policy to promote breastfeeding.” The bill
asks hospitals to consider guidance from the Baby-Friendly Hospital Initiative in developing
their policies (O’Mara, 2012).
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In 2011, the US Surgeon General issued a “Call to Action” concerning the low
breastfeeding rates in the United States (U.S. Department of Health and Human Services, 2011).
The call to action recognizes the BFHI to be a promising strategy to improve the care provided to
new mothers (Joint Commission on Accreditation of Healthcare Organizations, 2006). The
Baby-Friendly Hospital Initiative is part of Action 7, which is to ensure that maternity care
practices throughout the United States are fully supportive of breastfeeding. The implementation
strategies for Action 7 are to accelerate the implementation of the Baby-Friendly Hospital
Initiative and to establish transparent, accountable public reporting of maternity care practices in
the United States. The 2011 report card based off of the mPINC survey administered by the
CDC recommends the State of Ohio to increase adoption of the BFHI in Ohio hospitals and
birthing centers (“Maternity Practices in Infant Nutrition and Care in Ohio”, 2011).
The California WIC association found, “Disparities in in-hospital rates of exclusive
breastfeeding are not found in hospitals that have implemented the policies and practices of the
Baby-Friendly Hospital Initiative, while the opposite is true in hospitals that are in the same
geographic region but are not designated as Baby-Friendly (California WIC Association, 2008).”
Perrine and colleagues found that, “Two-thirds of mothers who intend to exclusively breastfeed
are not meeting their intended duration. Increased Baby-Friendly hospital practices, particularly
giving only breast milk in the hospital, may help more mothers achieve their exclusive
breastfeeding intentions.” Saadeh (2012) found, “The BFHI has led to increased rates of
exclusive breastfeeding, which are reflected in improved health and survival1. The BFHI has had
great impact on breastfeeding practices among both healthy and sick infants.”
1 The improved health and survival is due to the health benefits of nursing, such as decreased risk of SIDS and
diarrhea.
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As of September 12, 2012 there are currently four "Baby-Friendly" Hospitals in Ohio and
143 throughout the United States. The four hospitals in Ohio that have received designation are:
Lakewood Hospital (Cleveland, OH), Southview Hospital (Kettering, OH), Mercy Hospital
Anderson (Cincinnati, OH), and Mercy Hospital Fairfield (Cincinnati, OH) (“Baby-Friendly”).
Several hospitals in Ohio are in the process of becoming "Baby-Friendly", but Baby-Friendly
Hospital Initiative USA will not disclose the list of hospitals in the process of receiving the
designation2. The National Institute for Child Health Care Quality has a grant to help 90
hospitals become "Baby-Friendly" with the support of the Centers for Disease Control and
Prevention. The aim of this program, known as Best Fed Beginnings, is to improve maternity
care and increase the number of "Baby-Friendly" hospitals in the US. Currently five hospitals in
Ohio are part of this program including: Atrium Medical Center (Middletown, OH), Doctors
Hospital (Columbus, OH), Riverside Methodist Hospital (Columbus, OH), Summa Health
System (Akron, OH), UC Health/University Hospital (Cincinnati, OH), and University Hospitals
MacDonald Women’s Hospital (Cleveland, OH) (“Best Fed Beginnings”).
There is a need in Ohio to increase lactation rates for the health of Ohio babies and
mothers. The Surgeon General’s support of "Baby-Friendly" coupled with the evidence
suggesting the benefits of implementing the Ten Steps, leads one to consider why so few
hospitals in the United States and specifically Ohio have obtained Baby-Friendly Hospital
Initiative designation. Through interviewing the four "Baby-Friendly" hospitals in Ohio, this
paper aims to better understand the process, benefits, and challenges the hospitals faced in
achieving designation. The information from the interviews combined with the policy analysis
will provide information for making generalizable findings about BFHI and its application in
2 In an informal discussion with Baby-Friendly USA, the representative told the researcher that there had been a few
sabotage attempts on hospitals once it was disclosed that certain hospitals were undergoing the ten steps.
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Ohio hospitals. The significance of this research is that it will assist policy makers, hospital
administrators, and the general public to better understand the BFHI and its application in Ohio
hospitals. This research provides generalizable knowledge as to whether BFHI is a possibility
for Ohio hospitals to initiate in order to improve breastfeeding rates in Ohio to meet the Surgeon
General’s “2011 Call to Action” and the Healthy People 2020 goals.
Part 2: Methods
A systematic literature and policy analysis of the Baby-Friendly Hospital Initiative
(BFHI) was completed in order to understand the historical context of lactation in the United
States, trends in lactation in Ohio, the Baby-Friendly Hospital Initiative and the impact and
expansion of the BFHI. Following the literature review and policy analysis, the researcher
conducted three semi-structured, hour-long telephone interviews with lactation staff representing
all four hospitals in Ohio with BFHI designation. One of the interviewees was involved in
aiding two hospitals in obtaining BFHI designation. Prior to contacting the hospitals, the
researcher received institutional review board approval by the University of Cincinnati
Institutional Review Board3.
Interviewees were recruited through the lactation department of each of the four
hospitals: Mercy Hospital Fairfield, Mercy Hospital Anderson, Southview Medical Center, and
Lakewood Hospital, which are listed on the "Baby-Friendly" website:
http://www.babyfriendlyusa.org/eng/03.html. Through talking with the department, the
researcher found the appropriate contact person to phone interview. Once the researcher
3 See Appendix 1 for IRB approval
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confirmed she had the appropriate contact person, the researcher arranged a one-hour phone
interview.
The researcher took notes on her computer during the interview. The interviews were not
audiotaped. All interviews were conducted using the same semi-structured interview over the
period of two months (September and October of 2012). After completing the interviews, the
researcher independently identified categories and performed a theme analysis of the qualitative
data. The findings from the interviews, combined with the policy analysis, provide data for
making generalizable findings about BFHI and its application in Ohio hospitals. The interviews
were guided by the following questions:
1. In what year did your institution become "Baby-Friendly" (BF)?
2. To the best of your knowledge, how long did the process take?
3. Who made the decision to become BF?
a. (If known), How was the decision expressed to the staff?
i. Was it received well among the staff?
1. Why or why not?
4. To the best of your knowledge, what steps were taken at your organization to become
BF?
a. Were certain steps harder/ longer than others?
i. (If yes), Which ones and in which ways were they more challenging?
1. (If yes), Can you tell me more about step x, step y, etc.?
b. Were certain steps easier/ quicker than others?
i. (If yes), Which ones and in which ways were they simpler to implement?
1. (If yes), can you tell me more about step x, step y, etc.?
5. Were there barriers to becoming BF?
a. (If yes), Can you tell me more about barriers 1, 2, 3, etc.?
6. What have been the biggest positive changes that you have seen as a result of becoming
BF?
a. (If have positives), Can you tell me more about positive 1, 2, 3, etc.?
7. Were there any negatives to becoming BF?
a. (If yes), Can you tell me more about negatives 1, 2, 3, etc.?
8. Would you recommend others hospitals go through the ten steps?
9. What are some reasons for a hospital to become BF?
a. Can you tell me three positive aspects for a hospital to become BF?
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10. Are there any reasons why a hospital would/should not become BF?
These ten main questions and sub-questions helped the researcher to identify certain themes
concerning the experience of the BFHI in Ohio hospitals. The researcher arrived at the
following theme analysis by analyzing the qualitative findings from the three interviews and
categorizing and compiling the content from the interviews.
Part 3: General Observations and Theme Analysis:
This chapter contains two components: the participants general observations including
the costs and benefits of obtaining the “Baby-Friendly” designation and a theme analysis of
issues faced by respondents as they implemented the Ten Steps.
General Observations:
The Baby-Friendly Hospital Initiative was viewed positively among all research
participants. Although, the process and challenges that each hospital faced may have been
unique, each interviewee recommended that other hospitals should go through the Ten Steps. All
participants believed the time, energy and expense were worthwhile because the results were so
profound. As one interviewee proudly exclaimed, “"Baby-Friendly" designation does what is
best for mothers and babies.”
Towards the end of the interview, the researcher asked the participants to rate the top three
reasons to become "Baby-Friendly" and the following are their responses in order by frequency.
1. Increase initiation of breastfeeding
2. Provides support, promotes breastfeeding, and supports breastfeeding
3. Health and wellness for mom and baby
4. Good marketing to say the hospital is "Baby-Friendly"
5. Babies just do better- far fewer babies in the nursery, less monitoring of babies
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6. Joint commission has made exclusive breastfeeding as one of their core measures.
Upon asking if there were reasons for not becoming "Baby-Friendly", two issues were
suggested: the costs associated and the time associated with obtaining designation. Cost was the
biggest barrier. It is expensive to apply for designation, to train staff, and to maintain the
designation. Nevertheless, it was unanimously deemed worth the expense. One interviewee put
it, “The results are well worth the time and money.”
There were several foreseeable costs in becoming "Baby-Friendly" for a hospital. The
most significant included: paying for formula, replacing things branded by formula
manufacturers, paying for staff and physician education, staffing support groups and extra
lactation services, and paying for the application to obtain designation.
Formula manufactures usually give hospitals free formula so long as hospitals distribute
formula gift bags upon discharge from the hospital. Since "Baby-Friendly" forbids the
distribution of formula gift bags, hospitals must pay for formula. One hospital found that paying
for formula was budget neutral. In paying for the regular formula they were able to effectively
negotiate more expensive formulas needed for babies with special needs (ex. lactose intolerant).
The other hospitals did not discuss if paying for formula was a financial burden on the
institution. One hospital discussed that it created a take home bag that included coupons for
breastfeeding mothers, freezer bags to store frozen breastmilk, and water bottles. This
breastfeeding friendly take-home bag replaced the formula gift bags.
Replacing branded items was an unanticipated expense for most hospitals. Items like
pens, mugs, nametags, crib carts, and measuring tapes provided by formula manufacturers
sported their logos. Items bearing logos of formula manufacturers are also prohibited by the Ten
Steps. Purging all the logoed items was time consuming. Many of the hospitals discussed their
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disbelief regarding how many displayed advertisements. Replacing the branded items at a clinic
that feeds into the hospital is also an expense because the hospitals had to provide material in
place of all the items formula companies provided. All of the things provided by formula
manufactures had to be replaced and paid for by the institution.
Paying for staff education was another cost. The costs involved time (18 hours for nurses
and 3 hours for physicians) and money (if a course such as Jones and Bartlett was purchased).
Staffing support groups and clinics were additional costs that many non-"Baby-Friendly"
hospitals were already paying. Half of the hospitals had pre-existing support groups prior to
becoming "Baby-Friendly". The requirement for the support group does not mandate that a
lactation consultant be present. It could be led by volunteers or could be affiliated with another
lactation support group such as La Leche League International. Paying for a lactation clinic is an
added expense, but it is not required by the Ten Steps. This is an optional step that hospitals can
take to further support nursing mothers. Finding creative ways to fund it could potentially make
it budget neutral. This includes charging a small fee for use or having a boutique that sells
breastfeeding items such as pumps where the profits go towards funding the center.
Applying for "Baby-Friendly" designation is not free. The fee for hospitals with more
than 500 births a year is $3000 for each of the following phases: development, dissemination and
designation. An additional $1000 fee is paid to "Baby-Friendly" annually after designation is
received. There are lower fees for hospitals and freestanding birth centers with under 500 births
per year.
A research study performed by DelliFraine et. al (2011) found, "Becoming baby-friendly"
is relatively cost-neutral for a typical acute care hospital. Although the overall expense of
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providing baby-friendly hospital nursery services is greater than nursery service costs of non–
baby-friendly hospitals, the cost difference was not statistically significant. "
Every hospital felt that the benefits of becoming "Baby-Friendly" far outweighed the
challenges that each institution faced in obtaining and maintaining designation. One interviewee
insisted, “This is the right thing to do!” Another said, “Yes, definitely! It is, because this is how
it is meant to be.” A third says, “It is great, moms and babies will get what they need. It is what
is right, and we need to move forward!” "Baby-Friendly" even benefits formula feeding
mothers by encouraging rooming-in and skin-to-skin.
Every hospital saw increases in breastfeeding initiation. The state of Ohio requires all
hospitals to chart breastfeeding at discharge. The hospitals are not required to follow-up to see if
breastfeeding is sustained. Two of the hospitals experienced around twenty percentage point
increases in their breastfeeding rates (from the mid-60’s to the mid-80’s). Two others had been
growing slowly (at about 1 percentage point every two years since the institutions began keeping
track in 1990). After receiving designation, those hospitals experienced four percentage point
increases in one year. The reasons these rates did not go up as much as the other two hospitals is
that one third of the Ten Steps were already in place in both institutions. The institutions were
already doing rooming-in, classes, support group, etc. The hospitals have all witnessed
breastfeeding rates that have gone up. It is hard to determine how much of the increase resulted
from people becoming more aware of breastfeeding benefits and how much is from "Baby-
Friendly". Still, the fact that each institution saw such large increases immediately following the
full implementation of "Baby-Friendly" indicates it had an impact.
Although these increases in breastfeeding initiation are promising, it is hard to tell if they
will lead to an increase in longer-term rates, such as exclusively breastfeeding at six months.
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One hospital suggested that they saw a huge drop-off after six weeks and three months when
many mothers return to work. The hospital that was tracking estimated that, “Of the people who
start, maybe 15 percent make it the year. This is still not enough!”
Theme Analysis:
Although "Baby-Friendly" was viewed positively among participants, each hospital had
unique experiences in the process of obtaining designation. Every hospital is a unique
environment defined by a unique set of relationships, a unique administration, and a unique
culture. As such, each hospital approached "Baby-Friendly" differently. The following theme
analysis serves as the compilation of the findings from the three semi-structured interviews into
key themes. Three key themes developed with several sub-themes, which include: policy,
education, and hospital personnel.
Theme 1: Policy
The process of becoming "Baby-Friendly" requires new policies to be developed by
hospitals to implement the Ten Steps. The policy changes that need to occur require both a
change in written policy and in hospital practice. The changes to hospital policy can be very
time consuming and affect the length of time it takes to receive designation. The first of the Ten
Steps is to have a written breastfeeding policy that is routinely communicated to all health care
staff.
Written Lactation
Policy
Baby Friendly USA Support
Timing to Designation
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Written Lactation Policy:
*As part of the theme analysis, the author provides her recommendations to each sub-theme
under the italicized sub-theme headings.
Hospitals implementing "Baby-Friendly" should seek to:
1. Implement model policies which are available from Baby-Friendly USA.
2. Use Baby-Friendly USA as a resource, when a challenge arises.
The written lactation policy for some hospitals was the easiest step and for others was a
big hurdle. One hospital shared that the biggest hurdle was trying to figure out everything that
needs to go into a policy with a group of people. Working as a group can be a challenge because
people have different opinions and it can be hard to come to consensus. One interviewee
suggests, “Thinking of everything that goes into a policy is an ongoing process. We are
constantly making changes.” One hospital discussed how helpful Baby-Friendly Hospital
Initiative USA was in writing their policy. The interviewee said, “"Baby-Friendly" walked us
through the steps.” The same hospital representative also talked about how helpful the other
"Baby-Friendly" Hospitals in the state were with writing the policy, and report that they visited
another "Baby-Friendly" Hospital while working on their designation. Two hospitals suggested
that the written policy was not a barrier because "Baby-Friendly" has samples that served as the
basis for their own policies.
Support from Baby-Friendly Hospital Initiative USA:
All of the hospitals discussed how helpful Baby-Friendly Hospital Initiative USA was in
their process to achieve "Baby-Friendly" designation. Whether it was writing the policy
document, or answering a simple question, the organization provided support throughout the
process if a hospital asked for it.
Timing:
Hospitals implementing "Baby-Friendly" should seek to:
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1. Complete an internal audit to gain a better understanding of what already exists and what
steps need to be implemented.
2. Have hospital leadership remain cognizant of the impact of size. For example smaller
hospitals can typically obtain designation faster.
All four hospitals that are currently "Baby-Friendly" in Ohio have received the
designation over the last ten years. The time to receive designation depended on many factors
including: size of maternity unit, number of lactation consultants, independence of management
decision making, management motivation, and number of "Baby-Friendly" steps already in place
prior to beginning the process. The fewer steps that needed to be implemented, the more
streamlined and fast tracked the process was. For this reason, hospitals that already have some of
the Ten Steps implemented will have fewer steps to complete to receive designation, shortening
the process. Participants perceived that it was easier and faster for smaller birthing units to
receive designation because fewer staff needed to be trained and fewer people needed to buy-into
the idea of "Baby-Friendly".
The time to designation for the hospitals in Ohio spanned from three years to nearly a
decade. The first two hospitals in Ohio to receive the designation, received it one day a part
(October 2003) and were part of a larger system that sought to have all birthing centers in the
system receive the designation. A third hospital in this system received BFHI designation in
2002, but is no longer operating a maternity unit. The process for the staff at the two hospitals in
the system that are still "Baby-Friendly" took nearly a decade from conception of the idea to
receiving the designation, with the majority of the efforts towards obtaining the designation in
the final year (2002-2003). A third hospital in the state of Ohio received designation in 2008.
This hospital was able to complete the process in three years. This hospital is relatively small,
with less than 2000 births per year and a sufficient number of lactation consultants (nine) to
provide lactation services to patients. The fourth hospital received designation in 2012 after
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about five years of work. This probably took a bit longer than it should have because they were
working with a consortium of birthing hospitals in a system. This hospital was the first to ask
management in the system to obtain BFHI designation and was the first to receive designation.
Theme 2: Hospital Personnel
The process of becoming "Baby-Friendly" requires the cooperation of lactation
consultants, nurses, physicians, maternity unit staff, and hospital administrators. This requires
buy-in from all parties. Even with buy-in, there are unique challenges for nurses and physicians
that must be addressed in order to implement "Baby-Friendly".
Decision Makers:
Hospitals implementing "Baby-Friendly" should seek to:
1. Recognize that there is no one best approach to BF as the decision to achieve BFHI can
come from top down or bottom-up.
2. Minimize staff turnover, which can cause disruptions and delay implementation.
The decision to become "Baby-Friendly" is one that requires a tremendous amount of
time and effort between management, lactation staff, and the staff of the maternity unit including
Decision Maker
Buy-in
Physicians
Nurses
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physicians and nurses. The person or group that initiated "Baby-Friendly" varied from hospital
to hospital.
In two of the hospitals, maternity unit managers with system-level management support,
made the decision to become "Baby-Friendly". There had been system level attempts prior, but
when the visionary leader left, the process halted. Designation was successfully accomplished
when management came to the lactation consultants with a time frame.
Another hospital staff decided as a group to become "Baby-Friendly". The instigator for
this hospital was an education coordinator on the birthing unit, but the process and decision to
become "Baby-Friendly" was a group effort. The Chief Executive Officer at the hospital was
very excited about "Baby-Friendly" and supportive.
A fourth hospital pursued "Baby-Friendly" because the director of the hospital and the
manager of the maternity department decided to pursue it. The president of the system and the
vice president and administration needed to be behind it. This institution prepared a presentation
and spoke with the system level officials. They were not thrilled with the idea, but also did not
really care. The manager noted that the men were uncomfortable discussing lactation. The
manager attempted to make the men in the room comfortable with the topic by framing it as a
health issue.
The variety of decision makers demonstrates that each institution has its own culture and
runs differently. This also shows that "Baby-Friendly" can come from top level management
down, as occurred in hospitals one, two, and four, or it can come from the bottom to the top as
occurred in hospital three. The consistent factor was continued determination to become "Baby-
Friendly". The most likely hurdle decision makers encountered was staff turnover. Without the
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visionary behind "Baby-Friendly" keeping the ball moving, it can get lost in the day to day
demands of a busy maternity unit.
Buy-in:
Hospitals implementing "Baby-Friendly" should seek to:
1. Keep staff informed of changes and steps being taken.
2. Foster organizationally relevant approaches (multi-pronged and direct approaches).
3. Inform the staff about "Baby-Friendly" early and often throughout the process.
Becoming "Baby-Friendly" requires changes in the way the maternity unit of a hospital
functions in fundamental ways, whether it is getting a baby skin-to-skin to initiate breastfeeding
within one hour of birth or having the newborn room-in with mother. These changes require
changes in the way the staff of the unit function, and require buy-in to be successful. The four
hospitals used many strategies to get staff to buy-into "Baby-Friendly".
All four hospitals acknowledged that there is going to be resistance with change. The
consistent factor that led to successful buy-in was keeping the staff on the unit informed about
becoming "Baby-Friendly". One hospital achieved buy-in by taking a multi-pronged approach.
This included: educating the staff about "Baby-Friendly" at staff meetings, having lactation
consultants hold discussions with different staff members, bringing staff into the room when a
lactation consultant was working with a mother, putting information about it in staff newsletters,
placing little information sheets and teaching tools on bathroom doors in staff bathrooms, and by
making sure "Baby-Friendly" information was widely available. This hospital made sure to
include the general staff in each step and continued to keep the staff informed as the process
continued. The other hospitals took the approach of advising/informing the staff that this is the
direction that the hospital is going at a staff/unit meeting or several staff/unit meetings.
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Regardless of if a multi-pronged approach or a direct approach was taken, the key to success was
informing the staff about "Baby-Friendly" early and often throughout the process.
Nurses:
Hospitals implementing "Baby-Friendly" should seek to:
1. Provide continuing education to respond to the needs of the staff
2. Provide continuing education with flexible times.
3. Insure that lactation consultants are available to answer questions
4. Assist nurses during the process of adapting to new workflows.
Getting nurses on board with "Baby-Friendly" was a consistent challenge among the four
hospitals. The longest tenured nurses were the hardest to get on-board with "Baby-Friendly",
since there were fundamental changes that had to occur in nurse workflow. One lactation
consultant explained,
One of the difficulties that we encountered was that so many nurses did not breastfeed.
We had to show the nurses breastfeeding is best. It is hard to admit that what I did (not
breastfeeding) was not best. You do not want to make nurses and staff feel guilty, yet,
you need to tell mothers what is best.
The following five challenges were the most frequently brought-up among the hospitals:
1. The nurses had to get the baby skin-to-skin within one hour. This is a challenge because
it requires a change in workflow.
2. The nurse had to bathe the newborn in the room with the mother so that the baby would
room-in at least 23 h-ours of a day. This is a change in workflow.
3. Nurses could no longer offer formula or a pacifier to a newborn, unless it was medically
indicated. This is a change in practice and often workflow. It is a change in practice
because formula is not offered unless medically indicated. It is a change in workflow
because nurses may need to provide education about pacifiers and supplementation.
4. Nurses needed to discourage mothers from using the nursery if a nursery was available.
This is a change in practice because it requires nurses to serve as educators about the
benefits of rooming-in.
5. All nurses had to obtain 18 hours of continuing education in lactation.
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These challenges were addressed by the hospitals in different ways. Nurses have many
requirements when it comes to achieving "Baby-Friendly". For full-time nurses, it is hard to find
time for anything additional beyond the day to day demands of the job, and becoming "Baby-
Friendly" requires several fundamental changes in the way that a nurse works with mother and
newborn. For the first four issues, the hospitals mainly addressed them through staff meetings,
discussions, and through education.
To overcome the first four challenge, some of the hospitals developed targeted strategies.
One hospital, to prevent supplementation, especially at night, practiced scripting with nurses.
This scripting served to be both supportive and educational for the nurses. This is an ongoing
process for all the hospitals. Two hospitals either eliminated or minimized the nursery in order
to handle rooming-in. One hospital was in a research study on skin-to-skin with another
hospital. The nurses bought into skin-to-skin right away because the babies were so much more
stable and breastfed easier. Two hospitals focused on hand expression to deal with challenge
three. The nurses at these hospitals were all taught how to teach mothers how to use hand
expression, which was either done directly into a baby’s mouth or with the use of a spoon or cup
directly into mouth. There is a booklet called Enjoy, which explains hand expression, and was
given to all breastfeeding mothers.
The fifth issue required creativity among the different hospitals to address. Two
hospitals' lactation departments obtained continuing education hours for the staff by offering a
variety of courses during different shifts and days. They were very flexible with the schedules of
the nurses. The lactation staff made “luncheon specials” where they would sit down with the
nurses during the lunch hour. The lactation staff made themselves very available to the nurses.
This included having the nurses round with the lactation staff and the lactation staff observed the
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nurses. The lactation staff made sure the nurses were comfortable with assisting in lactation.
The lactation consultants had check off lists for the nurses. One of the hospitals provided
independent study packets that the nurses could bring home. A second hospital adopted the
independent study packets as another way for the nurses to obtain their 18 hours. A third
hospital used a Jones and Bartlett 10-step education program, which cost the institution $90 per
person to fulfill the 18 hours of required continuing education. The Jones and Bartlett program
is specifically created to assist hospitals in getting their staff trained for "Baby-Friendly". A
fourth hospital had an educator put the entire education piece together for the institution. The
support of the educator streamlined this step for this particular hospital.
One of the hospitals took the approach of trying to hire nurses who are already lactation
consultants. These nurses prove to be versatile as they can cover for a lactation consultant or
another nurse. This also minimizes the amount of extra training that is needed when a new nurse
is hired.
Physicians:
Hospitals implementing "Baby-Friendly" should seek to:
1. Provide continuing education at flexible times.
2. Provide continuing education in a variety of delivery modalities (e.g. on-line)and with
multiple options .
3. Award and reward physicians for adopting desired "Baby-Friendly" behaviors.
4. Provide literature on lactation at physician offices in place of literature distributed by
formula manufacturers.
Just as there are many obstacles to obtaining buy-in for a nurse, there are also challenges
with training physicians and getting them to adhere to "Baby-Friendly" practices with regards to
skin-to-skin, exclusively nursing, rooming-in, and not handing out formula gift bags. The four
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hospitals have created many successful strategies to overcome the hurdles associated with
physicians.
1. 3 hour CME Requirement:
For physicians, three hours of continuing medical education (CME) are required. Getting
the physicians to find time for training was a problem. One hospital had a house doctor who was
supportive of "Baby-Friendly" and created a website for physicians with articles. Another
hospital sent mass emails to doctors’ offices when a famous physician who specializes in
lactation, Dr. Ruth Lawrence, came and lead grand rounds at a local hospital. The email
advertized the grand rounds as a great way to get started on CMEs and the grand rounds was
recorded and made available on the Internet. The hospital also offered a two hour-long class that
counted for two credit hours of CMEs that was led by a pediatrician and an obstetrician and that
was recorded. The topics were applied to pediatrics and obstetrics. The video was sent to every
physician’s office with a letter about the grand rounds.
2. Skin-to-skin
For one hospital, which is smaller (roughly 700-800 births a year), all of the physicians
bought in immediately. A new group of anesthesiologists joined the hospital, and had no
problem doing skin-to-skin right after a Cesarean section. This group was very flexible. They
did not have any “tough, good, old boys” to contend with. Since this hospital was part of a
research study with another institution, that was studying skin-to-skin, this process was already
underway.
The other hospitals struggled with skin-to-skin. It was through staff training and
educating the nurses that this was accomplished.
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3. Rooming-in
This was a challenge for pediatricians because the exam has to be done in the new
mother's room. This causes a change in workflow, since all of the babies have to be observed in
different rooms and cannot be observed at once in the nursery. In order to encourage
pediatricians to do this, one hospital had an education coordinator that gave gold medals and
rewards to the pediatricians for doing it. The hospitals that had eliminated or minimized their
nurseries did not have to overcome this barrier.
4. Giving lactation a chance
All the hospitals had to seek strategies to work with physicians trying to pre-maturely
supplement. Physicians often argue that formula is medically indicated, when it really is not the
right thing to do. The key to handling this was continuing to educate physicians about best
practices in lactation.
5. Physicians’ offices
A barrier, that is a continuous hurdle, is trying to eliminate formula bags from physicians’
offices. If a physician’s office is part of the hospital, then it can be influenced by the hospital. It
is more of a challenge for an independent physician, who has an office out of the control of the
hospital. The pre-natal piece is a problem because patients need to be educated in physician
offices. Clinics that feed into a hospital are simpler. One hospital created material for the
physician’s waiting rooms to educate expectant mothers about lactation. Another hospital also
created material for the waiting rooms for expectant mothers as well as had games available that
were about lactation for expectant mothers and gave little prizes to mothers who completed the
games. In a clinic that feeds directly into a "Baby-Friendly" Hospital, all formula advertisements
must be eliminated. Since most parenting magazines are covered in formula advertizing, it is
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critical to have something to replace this material with that can be flipped through while waiting
for a physician or nurse midwife.
Theme 3: Patient Education
Patient education is a key aspect of "Baby-Friendly" and represents two of the Ten Steps.
Patient education is divided into pre-natal education and post-natal education and support. The
Ohio "Baby-Friendly" hospitals had innovative ways of educating expectant and new mothers
about the benefits of lactation.
Pre-natal Education:
Hospitals implementing "Baby-Friendly" should seek to:
1. Provide material on lactation at physician offices in place of literature distributed by
formula manufacturers.
One of the biggest challenges a hospital in Ohio faces is that most women who come to
the hospital for delivery have already made their decision on how they will feed their newborn.
For this reason, pre-natal education is crucial. All of the hospitals offer pre-natal education
courses, including one on lactation. Although this is in place, it is not necessarily sufficient
when it is combined with excess formula advertising outside of this course. Advertizing is
prevalent in mothering magazines, physicians’ offices, mailings, and giveaways. Since
independent physician practices are not regulated by the hospital, physicians must buy-in to
"Baby-Friendly" in order to change their own practices with regards to educating their patients
Pre-natal Education Post-natal Education &
Support Culture
Success Breastfeeding
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and restricting formula gifts. All the hospital representatives interviewed discussed this as an
ongoing challenge. The most successful thing was to create material for the physicians to hand
out as was discussed above.
Post-natal Education and Support
Hospitals implementing "Baby-Friendly" should seek to:
1. Develop support groups that attract new and expecting mothers.
2. Have a lactation consultant available at support group meetings.
3. Make a scale available at support group meetings.
4. Make the post-natal support programs open to all new mothers, regardless of infant
feeding choice.
5. Create a support group for mothers returning to work, as these mothers have unique
needs.
After leaving the hospital, many new mothers need ongoing support to successfully
continue breastfeeding. "Baby-Friendly" requires that support groups are available to new
mothers that can be referred to by the hospitals. Many of the hospitals have put together support
groups. One of the hospitals has a lactation consultant lead the group, although mothers take the
lead on the discussion. As an incentive to get mothers to come, the hospital provides a scale to
weigh newborns and infants. Also, since a lactation consultant is there, it is like a free lactation
consultant visit for new mothers. This is a big draw. One hospital discussed creating a special
support group just for mothers who are returning to work, since many breastfeeding mothers
choose to wean before returning to work. The goal is that the special support group can help
these breastfeeding mothers reach their breastfeeding goals.
One hospital went beyond the support group and created an outpatient lactation center.
Unfortunately, there is no money in it. The hospital is working on ways to make it profitable,
like having a boutique. The lactation center is open five days a week, and the hospital will see a
patient if the center is closed. Physicians were wary about sending patients to a lactation clinic.
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The key was building trust between lactation consultants and pediatricians. It was first a money
issue because mothers would go to the clinic instead of the pediatricians’ offices. But now that
trust has been built, the pediatricians regularly refer mothers to the clinic.
Culture
Hospitals implementing "Baby-Friendly" should seek to:
1. Be aware and sensitive of the different cultures of patient populations.
2. Make "Baby-Friendly" material available in different languages.
A key aspect of patient education is being aware of and sensitive to the various cultures
of the patients. Culture plays a role in much of Ohio, whether it is Appalachian culture in the
Southern part of the state that encourages bottle-feeding or immigrants in the northern part of the
state. Hospitals that are obtaining "Baby-Friendly" designation need to be aware of various
cultural issues.
In a hospital with a large immigrant community, the "Baby-Friendly" information was
posted around the unit in English, Spanish and Arabic. One hospital experienced a culture that
believed that there was no milk in the first few days, and the hospital provided an interpreter line
and sought to provide accurate information. This hospital tried to find relatives who could serve
as translators to the mother.
Hospitals in the southern part of the state must contend with Appalachian beliefs. These
beliefs are firmly seeded in bottle-feeding. There are also fears of hospitals and medical
interventions, which must be overcome. One interviewee shared the challenge of trying to
explain to patients that breastfeeding is best, when parents and relatives are giving conflicting
advice. This is a challenge as lactation consultants and nurses do not want to make parents and
relatives feel guilty. This is one of the many reasons why education is so important. One of the
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hospitals has an information sheet on "Baby-Friendly" for the patients, which discusses skin-to-
skin, not giving formula or pacifies, and rooming-in. The nurses use the sheet to educate the
patients.
Part 4: Discussion
The process of becoming "Baby-Friendly" can be a tremendous time commitment and
expense for hospitals, but can have profoundly positive outcomes in terms of improved infant
and mother health and increased lactation initiation. The information gathered reveals that the
hospitals and patients benefited from achieving BFHI designation. From the evidence in the
literature coupled with the findings from the interviews, it seems the question is not whether a
hospital should become "Baby-Friendly", but rather how a hospital should go about achieving a
designation. The findings from the semi-structured interviews have several implications for
implementing "Baby-Friendly" and here are nine recommendations based off of the findings.
First, a hospital must be aware of all of the costs associated with obtaining Baby-Friendly
Hospital designation. Costs can be minimized by being aware of potential costs at the beginning
of the process. This will allow a hospital maximum time to negotiate with formula
manufacturers, prepare budgets for fees associated with Baby-Friendly USA and different
education materials, and pay for additional staffing needs. Finding creative ways to fund
lactation support, such as having a boutique4 can help bring in revenue to reduce the net impact
of becoming "Baby-Friendly".
Second, hospital policy development is an ongoing process. This can be streamlined by
using model policies that are available from other hospitals as well as Baby-Friendly USA.
"Baby-Friendly" is available to help hospitals in the policy writing stage. To minimize time in
4 A boutique is a store that sells lactation products such as nursing bras, pumps, bottles, etc. Some lactation
boutiques also rent hospital grade breast pumps.
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getting a policy developed, it is important to assess the pre-existing steps that are in place and
speak with similar "Baby-Friendly" hospitals about what worked in their policies. It is critical
that if one staff member is in charge of implementation that there is not turnover without a
contingency plan.
Third, the decision maker can be from the top down or bottom up. This is important
because it shows that what matters is getting buy-in from all relevant parties. If a lactation
consultant wants to implement "Baby-Friendly", then she will be most successful if she gets buy-
in from the administration, other staff, nurses, and physicians. Without buy-in, it does not matter
how motivated the decision maker is. Becoming "Baby-Friendly" requires such fundamental
changes that the entire department must be on-board and included in the process. The
implementer might face challenges in discussing lactation with men who feel uncomfortable
about discussing lactation. It is important to keep the topic as a health issue. Using a formal
presentation that highlights the benefits of breastfeeding and the Ten Steps can make broaching
the subject with men easier.
Fourth, staff need to be informed and included in the process. This can be through
directly informing staff or a more multi-faceted approach. The critical strategy with regards to
the staff is keeping them informed about the changes that will be occurring and maintaining buy-
in. Placing information about "Baby-Friendly" in bathrooms and break rooms keeps staff
informed about the process and requires few resources. Also, progress should be discussed in
staff meetings so that staff are aware of what changes are taking place.
Fifth, continuing education programs for nurses and physicians need to be available at
flexible times and with multiple options. Having programs at different times, allows staff to
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have many opportunities to receive continuing education credits. Having a diverse set of options
allows clinical staff to tailor their education specifically to their interests and needs. For
example, a pediatrician might have an interest in something different than an anesthesiologist.
Providing topics of interest makes it easier to encourage completing CMEs.
A component of continuing education for nurses that can be beneficial is allowing nurses
to shadow lactation consultants. This can increase a nurse’s comfort with assisting mothers and
can allow the lactation consultant to answer any questions a nurse might have and assists in
fostering a trusting relationship between nurses and lactation consultants. A simpler, but more
expensive option for nurse education is to use Jones and Bartlett 10-step education program.
Sixth, incentivize new behaviors for physicians and nurses. Incentives such as gift cards
or recognition can go a long way in encouraging a new behavior or workflow. Since "Baby-
Friendly" requires many changes in workflow, positive reinforcement can ease the transition for
clinical staff. The prizes do not need to be large, a small gift card or reusable bag might be all
that is needed to incentivize a change. The incentives can serve to excite the staff and to remind
the staff about "Baby-Friendly" and why the changes are happening.
Seventh, provide material on lactation at physician offices in place of literature
distributed by formula manufacturers. This literature should be educational and provide
resources for further information about lactation. This can include contact information for the
support groups that are available through the hospital. The material should also be culturally
sensitive to the location. If a hospital has a large Spanish speaking population, then the brochure
should be in Spanish. The hospital can also provide games, such as a crossword or word search
and provide small rewards for playing the games in the waiting room.
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Eighth, support groups need to have a draw for them to be effective. Having a lactation
consultant available to answer questions can be a draw for a new mother to attend, since she can
get a free consultation or answer to questions concerning lactation. The lactation consultant can
also help to structure the meeting so that the discussion is meaningful for participants. Having a
scale can also be a draw for new mothers anxious as to whether a newborn is gaining weight.
Since typically the infant scales are only available at a physician’s office or hospital, a free scale
can incise a mother to attend.
Finally, each hospital must assess what steps of the Ten Steps need to be accomplished
and be realistic about the challenges that each step will present. Since each hospital has unique
challenges, what is easy for one hospital might be a challenge for another hospital. The different
mix of administrators, staff, physicians, and nurses in each hospital, means that the process to
becoming "Baby-Friendly" will need to be adapted appropriately.
Limitations and Recommendations for Future Research:
Because this was a qualitative study with a small sample, there are several foreseeable
limitations to the generalizability of the research. First, the sample size of four hospitals is not
representative of all types of hospitals in Ohio. Most notably, there are no academic medical
centers. A second limitation is that all hospitals in the sample are relatively small, with 2000 or
fewer births per year. A third limitation is that the participants may have had recall issues, since
designation occurred for three of the hospitals several years before the interview.
For future research, including hospitals that are in the process of obtaining designation
could expand the pool of available hospitals to interview. This would also insure that the facts
and details are accurately remembered by participants. Also, it might be interesting to interview
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hospitals that began the process and stopped or halted progress, to get a more complete picture of
the process of becoming "Baby-Friendly" and challenges and obstacles that hospitals might
encounter.
Part 5: Conclusions
The Ten Steps of the Baby-Friendly Hospital Initiative have benefited the four Ohio
Early adopters by creating facilities that provide best practice care to new mothers and newborns.
Not only did the hospitals find achieving designation to be nearly budget neutral, but they found
the results to be worth the time and resources. The Baby-Friendly Hospital Initiative is a path
towards providing optimal care for newborns and mothers and could be expanded in Ohio
hospitals to increase lactation rates, increase lactation support, and promote breastfeeding.
The unit of analysis in this study was the hospital. The process of becoming "Baby-
Friendly" is not focused on changing society, but on changing hospitals to focus efforts towards
promoting, protecting, and supporting lactation. The Centers for Disease Control and Prevention
state, " Birth facility policies and practices significantly impact whether a woman chooses to start
breastfeeding and how long she continues to breastfeed ("Breastfeeding Report Card—United
States, 2012")." It is at the hospital, where the vast majority of Ohio births occur, that new
mothers need to receive best practice care and support in order to successfully initiate
breastfeeding and have the confidence and support to continue it.
The findings from this research suggest several recommendations for hospitals to
consider when seeking Baby-Friendly Hospital Initiative designation. First, hospitals need to do
an internal audit to assess which of the "Ten Steps" need to be accomplished and what already
exists. Second, hospitals should use Baby-Friendly USA as a resource in the process towards
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designation. Third, a hospitals should take into account their size and set reasonable timeframes
for achieving designation. Fourth, involve staff in the process of becoming "Baby-Friendly" and
make continuing education flexible and appealing to the needs of the staff. Fifth, provide
literature and material about lactation to physician offices to make available in waiting rooms.
Sixth, make support groups available to new and expectant mothers with a lactation consultant.
Although this is only a sampling of the recommendations this paper found, the six highlight the
breadth and depth of the impact that achieving "Baby-Friendly" has on hospital staff,
administrators, lactation consultants, and expectant parents.
If Ohio hospitals strive to achieve Baby-Friendly Hospital Initiative designation, then
Ohio mothers and infants have the most likely chance at succeeding in setting and achieving
lactation goals. Enabling Ohioans to improve lactation rates, as Ohio is currently the 44th state
in the country in initiating lactation, is critical for the health of Ohio mothers and children. One
major step to improving the health of Ohio mothers and children is to increase lactation rates,
which cannot be accomplished without the support of hospitals. The Baby-Friendly Hospital
Initiative's Ten Steps have been proven to increase lactation rates in Ohio hospitals and around
the world. The time is now to take the right "Ten Steps" forward for Ohio mothers and babies.
Jill A. Gutmann
Capstone Project
38
Work’s Cited
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Capstone Project
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Capstone Project
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Appendix A.
Jill A. Gutmann
Capstone Project
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Appendix B
Key Lessons:
Written Lactation Policy:
Hospitals implementing "Baby-Friendly" should seek to:
3. Implement model policies which are available from Baby-Friendly USA.
4. Use Baby-Friendly USA as a resource, when a challenge arises.
Timing:
Hospitals implementing "Baby-Friendly" should seek to:
1. Complete an internal audit to gain a better understanding of what already exists and what
steps need to be implemented.
2. Have hospital leadership remain cognizant of the impact of size. For example smaller
hospitals can typically obtain designation faster.
Decision Makers:
Hospitals implementing "Baby-Friendly" should seek to:
1. Recognize that there is no one best approach to BF as the decision to achieve BFHI can
come from top down or bottom-up.
2. Minimize staff turnover, which can cause disruptions and delay implementation.
Buy-in:
Hospitals implementing "Baby-Friendly" should seek to:
1. Keep staff informed of changes and steps being taken.
2. Foster organizationally relevant approaches (multi-pronged and direct approaches).
3. Inform the staff about "Baby-Friendly" early and often throughout the process.
Nurses:
Hospitals implementing "Baby-Friendly" should seek to:
Jill A. Gutmann
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1. Provide continuing education to respond to the needs of the staff
2. Provide continuing education with flexible times.
3. Insure that lactation consultants are available to answer questions.
4. Assist nurses during the process of adapting to new workflows.
Physicians:
Hospitals implementing "Baby-Friendly" should seek to:
1. Provide continuing education at flexible times.
2. Provide continuing education in a variety of delivery modalities (e.g. on-line)and with
multiple options .
3. Award and reward physicians for adopting desired "Baby-Friendly" behaviors.
4. Provide literature on lactation at physician offices in place of literature distributed by
formula manufacturers.
Prenatal Education:
Hospitals implementing "Baby-Friendly" should seek to:
1. Provide material on lactation at physician offices in place of literature distributed by
formula manufacturers.
Post-natal Education and Support:
Hospitals implementing "Baby-Friendly" should seek to:
1. Develop support groups that attract new and expecting mothers.
2. Have a lactation consultant available at support group meetings.
3. Make a scale available at support group meetings.
4. Make the post-natal support programs open to all new mothers, regardless of infant
feeding choice.
5. Create a support group for mothers returning to work, as these mothers have unique
needs.
Culture
Hospitals implementing "Baby-Friendly" should seek to:
1. Be aware and sensitive of the different cultures of patient populations.
2. Make Baby-Friendly material available in different languages.
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