Closing the Quality Gap: Promoting Evidence-Based Breastfeeding Care in the Hospital
Closing the Quality Gap: Promoting Evidence-Based Breastfeeding Care in the
Hospital
Melissa Bartick, Alison Stuebe, Katherine R. Shealy, Marsha Walker and Laurence
M. Grummer-Strawn
Pediatrics 2009;124;e793-e802; originally published online Sep 14, 2009;
DOI: 10.1542/peds.2009-0430
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://www.pediatrics.org/cgi/content/full/124/4/e793
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2009 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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SPECIAL ARTICLES
Closing the Quality Gap: Promoting Evidence-Based
Breastfeeding Care in the Hospital
AUTHORS: Melissa Bartick, MD, MSc,a,b Alison Stuebe,
MD, MSc,c Katherine R. Shealy, MPH, IBCLC, RLC,d Marsha
Walker, RN, IBCLC,e and Laurence M. Grummer-Strawn,
PhDd
bDepartment of Medicine, Harvard Medical School, Boston,
Massachusetts; aDepartment of Medicine, Cambridge Health
Alliance, Cambridge, Massachusetts; cDepartment of Obstetrics
and Gynecology, Division of Maternal and Fetal Medicine,
University of North Carolina School of Medicine, Chapel Hill,
North Carolina; dDivision of Nutrition, Physical Activity, and
Obesity, Centers for Disease Control and Prevention, Atlanta,
Georgia; and eNational Alliance for Breastfeeding Advocacy,
Weston, Massachusetts
KEY WORDS
breastfeeding, hospitals, maternity, health care quality, quality
indicators, quality improvement, health care, infant, newborn
ABBREVIATIONS
CDC—Centers for Disease Control and Prevention
BFHI—Baby-Friendly Hospital Initiative
AAP—American Academy of Pediatrics
WHO—World Health Organization
UNICEF—United Nations Children’s Fund
P4P—pay for performance
mPINC—Maternity Practices in Infant Feeding and Care
NQF—National Quality Forum
AAFP—American Academy of Family Physicians
HEDIS—Health Plan Employer Data and Information Set
The findings and conclusions in this report are those of the
authors and do not necessarily represent views of the Centers
for Disease Control and Prevention.
www.pediatrics.org/cgi/doi/10.1542/peds.2009-0430
doi:10.1542/peds.2009-0430
Accepted for publication May 29, 2009
Address correspondence to Melissa Bartick, MD, MSc, Harvard
Medical School, Cambridge Health Alliance, 1493 Cambridge St,
Cambridge, MA 02139. E-mail: melissabartick@gmail.com
abstract
Evidence shows that hospital-based practices affect breastfeeding duration and exclusivity throughout the first year of life. However, a 2007
CDC survey of US maternity facilities documented poor adherence with
evidence-based practice. Of a possible score of 100 points, the average
hospital scored only 63 with great regional disparities. Inappropriate
provision and promotion of infant formula were common, despite evidence that such practices reduce breastfeeding success. Twenty-four
percent of facilities reported regularly giving non– breast milk supplements to more than half of all healthy, full-term infants. Metrics available for measuring quality of breastfeeding care, range from comprehensive Baby-Friendly Hospital Certification to compliance with
individual steps such as the rate of in-hospital exclusive breastfeeding.
Other approaches to improving quality of breastfeeding care include
(1) education of hospital decision-makers (eg, through publications,
seminars, professional organization statements, benchmark reports
to hospitals, and national grassroots campaigns), (2) recognition of
excellence, such as through Baby-Friendly hospital designation, (3)
oversight by accrediting organizations such as the Joint Commission
or state hospital authorities, (4) public reporting of indicators of the
quality of breastfeeding care, (5) pay-for-performance incentives, in
which Medicaid or other third-party payers provide additional financial
compensation to individual hospitals that meet certain quality standards, and (6) regional collaboratives, in which staff from different
hospitals work together to learn from each other and meet quality
improvement goals at their home institutions. Such efforts, as well as
strong central leadership, could affect both initiation and duration of
breastfeeding, with substantial, lasting benefits for maternal and child
health. Pediatrics 2009;124:e793–e802
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2009 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
PEDIATRICS Volume 124, Number 4, October 2009
Breastfeeding significantly predicts health outcomes for both mothers
and children. In 2007, the Agency for Healthcare Research and Quality
published a summary of systematic reviews and meta-analyses on
breastfeeding and health outcomes in developed countries and determined that early cessation of breastfeeding increases infants’ risks for
childhood obesity, gastroenteritis, necrotizing enterocolitis, leukemia,
otitis media, severe lower respiratory infections, sudden infant death
syndrome, and types 1 and 2 diabetes. Early cessation of breastfeeding
is linked with higher rates of maternal disease: breast and ovarian
cancers, type 2 diabetes, and postpartum depression.1 Infants who are
not breastfed incur up to $475 more health costs in the first year
compared with those who are exclusively breastfed for 3 months2
($671 in 2008 dollars3). Because many effects of breastfeeding are dose-
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e793
dependent, increasing breastfeeding duration can have a substantial impact
on public health.
Evidence shows that hospital practices
affect breastfeeding duration and exclusivity throughout the first year of
life,4–7 yet quality of breastfeeding care
in the United States is poor. In a 2007
Centers for Disease Control and Prevention (CDC) survey of ⬎80% of US
maternity facilities, the mean score
for implementation of evidence-based
breastfeeding care was 63 of 100 possible points.8 The 10 evidence-based
steps of the Baby-Friendly Hospital Initiative (BFHI) are known to increase
duration and exclusivity of breastfeeding when implemented, yet fewer than
3% of US hospitals are designated as
such.9 In some countries, all hospitals
are Baby-Friendly, and these countries
have strong government support, centralized leadership, and support from
the medical profession.10 The paucity
of US Baby-Friendly hospitals reflects
an endemic problem throughout
American health care: there is a significant gap between evidence-based recommendations and actual practice, as
detailed in the Institute of Medicine’s
2001 report, Crossing the Quality
Chasm.11 Closing this quality gap will
empower mothers to meet breastfeeding recommendations.
All major medical organizations, including the American Academy of Pediatrics (AAP) and the World Health
Organization (WHO), recommend 6
months of exclusive breastfeeding and
continued breastfeeding with appropriate complementary foods for at
least the first 1 to 2 years12–14; however, only ⬃12% of US infants are
breastfed exclusively for 6 months,
and only ⬃21% are breastfed for 12
months.15 Rates of any and exclusive
breastfeeding drop precipitously in
the first 2 weeks of life despite families’ frequent contact with the health
care system.
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BARTICK et al
The WHO/United Nations Children’s
Fund (UNICEF) Global Strategy for Infant and Young Child Feeding and the
American Public Health Association
urge immediate steps to improve
breastfeeding rates.14,16 The American
Public Health Association notes the
wide gap in the United States between
evidence-based care recommendations and current typical care. In this
article, we review data on quality of
breastfeeding care in US hospitals,
and we outline approaches to speeding adoption of best practices. We used
a PubMed search from January 1997
through April 2009 to identify Englishlanguage research done using the
term “breastfeed*” with the following
search terms: quality improvement,
quality management, performance incentives, and pay for performance
(P4P).
THE QUALITY GAP
Created in 1991, the BFHI is currently
the gold standard for evidence-based
breastfeeding care in hospitals (Table
1). Data continue to accumulate showing that adherence to the Ten Steps
predicts breastfeeding duration and
exclusivity, long after hospital discharge.4–7,17–19 Breastfeeding within
the first hour of life, exclusive breastfeeding in the hospital, and having a
written breastfeeding policy are the
steps generally found to have a the
greatest influence on success.4,18,20,21
The more steps that are practiced, the
higher duration and exclusivity of
breastfeeding at 2 months.4,6 DiGirolamo et al20 showed that breastfeeding
women who did not experience any of
the Ten Steps were 8 times more likely
to fail at breastfeeding by 6 weeks
compared with those who experienced
at least 6 of the steps. Individual steps
also affect outcomes. For example, 1
hospital-based intervention to reduce
formula supplementation of breastfed
newborns found that breastfeeding at
6 months increased to 87%, versus
66% beforehand.22
Despite strong evidence for the Ten
Steps, hospital compliance in the
United States is poor. The 2007 CDC
survey Maternity Practices in Infant
Feeding and Care (mPINC)8 sought to
survey all US maternity units, with
standardized questions based on their
implementation of the evidence-based
steps described in the BFHI. The CDC
survey addressed these issues from
the Ten Steps: (1) breastfeeding within
the first hour of life, (2) breastfeeding
on demand, (3) showing mothers how
to breastfeed, (4) prenatal education,
(5) absence of pacifiers, (6) rooming in
day and night, (7) absence of formula
supplementation without a medical
indication, (8) training of staff, (9)
breastfeeding support at discharge,
and (10) having a written breastfeeding policy that is conveyed to all staff.
TABLE 1 WHO/UNICEF Ten Steps to Successful Breastfeeding
1. Have a written breastfeeding policy that is routinely communicated to all health care providers.
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 1 h of birth.
5. Show mothers how to breastfeed and how to maintain lactation, even if they should be separated
from their infants.
6. Give newborn infants no food or drink other than breast milk, unless medically indicated.a
7. Practice rooming in: allow mothers and infants to remain together 24 h/d.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups, and refer mothers to them on discharge
from the hospital or clinic.
a The hospital or birthing site must pay fair-market price for all formula and infant feeding supplies that it uses and cannot
accept free or heavily discounted formula and supplies.
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SPECIAL ARTICLES
On the basis of a standard script, 1 respondent from each maternity center
answered the survey. To encourage
candid responses, respondents were
assured that their data would not be
publicly reported. Instead, each facility
was given a report comparing its results with benchmarks for other hospitals of similar size nationally and
with other hospitals in the same state.
Of a possible score of 100 points, the
average hospital scored only 63, with
the mean total scores ranging from 48
(Arkansas) to 81 (New Hampshire and
Vermont). Great regional disparities
were found, with the southern states
performing worse than the northeastern and western regions. Although
88% of facilities reported that they
taught most mothers techniques of
breastfeeding, practices that are
known to be detrimental to breastfeeding were common. For example, 65% of
facilities advised women to limit the
duration of suckling at each breastfeeding, and 45% reported giving pacifiers to healthy term infants.
Inappropriate provision and promotion of infant formula were common,
despite evidence that such practices
reduce breastfeeding success.4–6,23
Twenty-four percent of facilities reported regularly giving non– breast
milk supplements to more than half of
all healthy, term infants. These results
are consistent data from the Infant
Feeding Practices Study II, which found
that 41% of breastfed infants are supplemented with infant formula in the
hospital.15,24,25 Inappropriate supplementation has been associated with
shorter duration of breastfeeding in
multiple studies,7,20,26,27and it also incurs health risks that are associated
with nonexclusive breastfeeding.1,28
Moreover, the majority of facilities reported that they participate in formula
company marketing programs. Multiple studies have shown that formula
marketing packs reduce duration of
PEDIATRICS Volume 124, Number 4, October 2009
exclusive breastfeeding.23,29,30 Nonetheless, fully 70% of facilities reported giving commercial discharge packs that
contain infant formula to breastfeeding mothers. A separate study found
that 93% of hospitals give out any commercial discharge packs to at least
some mothers.31
The mPINC study results provide the
first national, systematically collected
data on the substantial gap between
best practices and routinely provided
maternity care. Underuse of these
evidence-based practices leads to premature weaning, with adverse consequences for maternal and infant
health.
BARRIERS TO QUALITY
IMPROVEMENT
Changes to Clinical Routine
Optimizing breastfeeding support will
require cultural changes in patterns of
care in hospitals. For example, on a
busy postpartum unit, it is much easier to offer a bottle than to diagnose
and resolve breastfeeding problems.
Similarly, removing the infant from the
mother’s room to perform a variety of
procedures (eg, photographs, newborn screening, examinations) may be
convenient for a busy hospital, but this
practice interferes with the mother’s
ability to breastfeed on demand. These
issues are substantial barriers to implementing Baby-Friendly practices, as
a national survey showed: hospitals reported that the most difficult steps
to implement were steps 6 (no supplements), 2 (staff training), and 7
(rooming in).
Formula Marketing
Doing away with hospital-based marketing of infant formula and paying fair
market value for formula have posed a
particular barriers to implementing
evidence-based care.19 Typically, most
US hospitals receive their well-infant
formulas free of charge from brand-
name manufacturers and in return are
expected to distribute commercial discharge packs that market that brand,
thereby implying endorsement from
the hospital. In Baby-Friendly hospitals, the cost of purchasing formula is
passed on in the room and board
charge, the same way food for other
patients is handled.
Safety-net hospitals such as Boston
Medical Center and San Francisco General Hospital have been able to achieve
Baby-Friendly status and pay for formula. Implementing BFHI also decreases costs of unused products
such as pacifiers, nipples, and discharge packs and saves on labor costs
and storage space required for discharge packs.32 Formula companies
have been known to overestimate
vastly the amount of formula that a
hospital requires, grossly inflating
projected costs.32 If hospitals wait to
pay for formula until they have implemented the other steps, then the need
for purchased formula is reduced.32,33
It may be helpful for hospital leaders to
know that severing ties from the formula industry is consistent with recent recommendations that the
health professions distance themselves from industry to avoid conflicts of interest that could compromise patient care.34,35
Attitudes and Beliefs
To implement elements of the BFHI,
supporters must negotiate varying attitudes and beliefs about breastfeeding. Norms for infant feeding have
changed dramatically in the past 3 decades. Some senior staff members,
many of whom have formula-fed their
own children, firmly believe that formula feeding is substantially equivalent to breastfeeding.36 A recent study
found that 45% of pediatricians surveyed agreed with the statement that
breastfeeding and formula feeding are
equally acceptable methods for feed-
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e795
ing infants.37 Others view infant feeding as a consumer choice, not a modifiable health behavior, and they are
reluctant to “push” mothers to breastfeed. Efforts to change breastfeeding
practices will have to address this tension between reinforcing medical recommendations and respecting patient
autonomy. Moreover, many providers
argue that maternity care has little or
no impact on breastfeeding success,
and they will need to be convinced that
practice changes matter. Finally, providers may lack the skills to address
basic breastfeeding needs, because
breastfeeding training in medical and
nursing education is limited, at best.38
Achieving 18 to 21 hours of training for
perinatal nurses has been described
as a significant barrier to achieving
Baby-Friendly certification, although
this is the minimum recommendation.19 This results in clinicians’ leaving
simple breastfeeding problems unresolved or relegating them to lactation
consultants, whose expertise is better
used for more complex issues.
METRICS FOR QUALITY
ASSESSMENT
Several metrics are available for measuring quality of breastfeeding care,
ranging from comprehensive BFHI certification to compliance with individual
steps, such as paying market value for
infant formula. Other metrics include
the distribution of formula company
discharge packs, mPINC scores, presence of an evidence-based written
breastfeeding policy, and the rate of
in-hospital exclusive breastfeeding
among breastfeeding infants. Each
metric has its advantages and disadvantages (Table 2).
The rate of in-hospital exclusive
breastfeeding among breastfed infants is especially promising for several reasons. First, it can be measured
as part of existing infrastructure for
collecting neonatal data, via genetic
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BARTICK et al
screening surveys or by modifying and
implementing the US Standard Certificate of Live Birth to collect this information. Second, to score high on exclusive breastfeeding, a hospital would
need to have successfully implemented many of the other Ten Steps
that are known to decrease the use of
supplementation and improve breastfeeding success, such as rooming in,
breastfeeding in the first hour of life,
and curtailment of formula marketing.
Finally, in-hospital exclusivity is patient centered, because its association
with improved breastfeeding duration
helps women meet their own breastfeeding goals. The National Quality Forum (NQF) recently endorsed the rate
of in-hospital exclusive breastfeeding
as a consensus standard for perinatal
care.39
APPROACHES TO IMPROVING
QUALITY OF CARE
To date, there have been few published
reports on approaches to improving
quality of care around breastfeeding.
Potential approaches include education of hospital decision-makers, recognition of excellence, oversight by
accrediting organizations, public reporting, P4P incentives, and regional
collaboratives.
Education of Hospital
Decision-Makers
There are a variety of opportunities to
educate and motivate key hospital
decision-makers to adopt evidencebased practices. Lactation consultants
and nongovernmental organizations
are often contracted by hospitals to assist with quality improvement around
breastfeeding. Regional meetings or a
summit of key leaders could help to
educate stakeholders and improve
networking opportunities and buy-in,
and these sessions could include training on implementation of best practices. Sharing peer-reviewed publications about the evidence for the Ten
Steps and about implementing them
can be influential, as can Web-based
resources. Often, an individual who
already works in the hospital leads
this type of educational effort, with
the regional effort from an outside
organization.
The mPINC survey was explicitly designed to educate decision-makers
and stimulate hospitals to implement
evidence-based best practices. The
CDC shared survey results with all
2690 participating hospitals and birth
centers, assigning each facility a set of
scores that compared their own practices with evidence-based practices,
highlighting those that are most problematic. The individualized reports
compared each hospital’s scores with
those in other facilities across their
state and the country and with those
of a similar size. These “benchmark
reports” included references to the
scientific literature explaining how
each practice affects breastfeeding
success. The CDC plans to repeat the
survey every 2 years so that hospitals can engage in continuous quality
improvement.
Grassroots movements can also serve
as a catalyst to draw the attention of
decision-makers around a specific
hospital practice. A growing body of evidence shows that commercial discharge packs are associated with decreased exclusive breastfeeding.29,40,41
The Ban the Bags campaign (http://
banthebags.org) has drawn attention
to the risks of hospital-based formula
promotion, attracting national press
coverage and encouraging hospitals to
reevaluate this practice.8,42 In addition,
state breastfeeding coalitions and
departments of public health have
awarded certificates to “bag-free” hospitals, helping incentivize efforts to improve quality of care.
Strong statements from professional
organizations can also encourage hospitals to adopt specific practices. The
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PEDIATRICS Volume 124, Number 4, October 2009
TABLE 2 Metrics That Can Be Used for Public Reporting and/or P4P Incentives and Related Advantages and Disadvantages
Facility Metric (Measure)
Method
Breastfed infants who receive 1. Feeding status as indicated in newborn
genetic screening or birth certificate
only breast milk during the
documentation 1. Rates of EBF in hospital
maternity stay (proportion
predict overall breastfeeding duration
of breastfed infants)
2. Infant formula dispensed from Pyxis
system
3. Prevalence determined from chart audit/
review
Facility designation by Baby-Friendly USA
mPINC survey score (score
out of 100)
Facility score based on responses to CDC
survey
Written breastfeeding policy
including core evidencebased breastfeeding
practices (yes/no)
Distributes formula company
discharge packs (yes/no)
Facility documentation of written policy
Price paid for infant formula
(price per unit purchased
relative to fair-market
price or 0 关received free of
charge from
manufacturer兴)
Facility self-report
Facility self-report
EBF indicates exclusive breastfeeding.
Disadvantages
2. High EBF rates reflect presence of
many of the Ten Steps
2. In states without current data collection
infrastructure, adoption would require either
amendments to the birth certificate or genetic
screening forms or periodic chart audit/review
3. Generally appropriately excludes those 3. Political and economic influence from the infant
formula industry could make establishment of
for whom breastfeeding is
Pyxis dispensation and tracking of infant formula
contraindicated (eg, HIV positive,
more difficult
dependent on drugs of abuse),
allowing for comparability across
facilities and patient populations
1. Requires no new assessment
1. Less than 3% of US hospitals are currently
infrastructure
designated Baby-Friendly, so it is not considered a
normative standard yet
2. Specifically identifies compliance with 2. Designation does not recognize partial
implementation
evidence-based practice and care
process measures
3. Ensures standardized compliance with
the Ten Steps
4. Status is widely regarded and
recognized
Provides a national, standard measure of 1. Because individual facility scores are confidential,
hospital practices and care processes
disclosure would be voluntary
included in the Ten Steps
2. Disclosure could affect accuracy of future survey
results
3. Scores are based on 1 individual’s report of
typical practices and care processes at each
hospital and have not been externally validated
Assessment is straightforward via either Written policies may not reflect actual practice;
there may be issues with accurate reporting
inquiry to facility or use of existing
mPINC data
1. Assessment is straightforward via
inquiry to facility
2. Reflects base level of commitment to
supporting breastfeeding
3. Reflects independence from
inappropriate marketing to patients
1. Assessment is straightforward via
review of purchase contracts
2. Reflects a commitment to supporting
breastfeeding
3. Reflects reduced influence from infant
formula manufacturers
Comments
1. The NQF has endorsed using EBF in the hospital as
a quality measure in part on the basis of success
in California of using this metric
Addresses only 1 of the important barriers to
breastfeeding
Definition of “fair-market price” may be difficult to
establish
2. This metric could easily be assessed and
adopted by HEDIS and was recently adopted by
Joint Commission
Federal oversight and/or a system for recognizing
partial implementation of the Ten Steps may be
necessary for hospitals to be able to pursue
financial incentives to implementing the Ten
Steps
Facilities’ mPINC scores could provide a baseline
for regional collaboratives to use to assess
progress by using quality improvement
strategies
The Academy of Breastfeeding Medicine has a
freely available model policy and provides a
template for hospitals to implement evidencebased practices
Facilities that have received awards for becoming
“Bag-Free Hospitals” have improved visibility
and recognition of the adverse effects of direct
formula marketing to patients
Growing awareness of the impact of “free” or
discounted brand-name pharmaceuticals has
drawn attention to ethical concerns about
hospital marketing of branded products
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Baby-Friendly status (yes/no)
Advantages
1. Feasibility of data collection varies
across states
AAP policy statement on breastfeeding13 outlines appropriate peripartum
procedures to facilitate the initiation
of breastfeeding, as does the statement from the American Academy of
Family Physicians (AAFP).12 The Academy of Breastfeeding Medicine has developed a model hospital policy to
guide hospitals.43
Recognition of Excellence
Several recognition programs honor
hospitals that practice evidence-based
breastfeeding care. The oldest and
most rigorous form of recognition is
Baby-Friendly designation. To qualify
as Baby-Friendly, a facility must apply
for a certificate of intent, implement
the Ten Steps, and undergo a site visit.
Baby-Friendly remains the gold standard because of its strong evidence
base and its origins from WHO and
UNICEF. Baby-Friendly status is highly
regarded by health professionals but
is largely unknown to the general
public.
Hospitals often are able to achieve the
Ten Steps by using standard quality
management techniques, such as the
“plan-do-check-act” model.44 Implementing certain practices, such as
skin-to-skin contact immediately after
birth, and increased staff training may
allow other steps to fall into place
more readily.
In addition to BFHI, several states have
developed recognition programs for
excellence in breastfeeding care. The
Texas Department of State Health Services has its own recognition program,
the “Texas Ten Step.” This program is
based on the BFHI, but compliance is
self-reported, and the program does
not require hospitals to purchase formula at fair-market value. The program offers staff training and encourages hospitals ultimately to obtain the
BFHI designation. As of April 2009, 68 of
190 hospitals had the Texas Ten Step
certification,45 but only 2 Texas hospie798
BARTICK et al
tals are designated as Baby-Friendly9
and only 6 have reported eliminating
commercial discharge packs.46 Other
state departments of health, such as
Oregon’s, have publicly recognized
hospitals that have eliminated commercial discharge bags, and Massachusetts is now following suit by recognizing bag-free hospitals and
other improvements in breastfeeding outcomes.
Oversight by Accrediting
Organizations
Accrediting organizations have considerableleverageinmodifyinghospital practices. The Joint Commission,
which accredits most US hospitals,
has set quality measures in many areas, with many more expected to follow. All of these metrics are publicly
reported and the subject of considerable attention by hospital administrators nationwide. Until recently, no
quality metric related to breastfeeding
was available from the Joint Commission. However, on July 20, 2009, the
Joint Commission announced that it
was adding ‘exclusive breast milk feeding’ as a new hospital Core Measure
for perinatal care, effective April
2010.47 It is likely that this new Core
Measure could have a tremendous impact on hospital practice and breastfeeding outcomes. It is likely that adding a breastfeeding metric, such as the
exclusivity rate, to the Joint Commission Core Measures could have a tremendous impact on hospital practice
and breastfeeding outcomes.
State regulations, promulgated by
state health departments, also represent an opportunity to improve breastfeeding practices; however, often states
do not have the resources or the political power to implement strong regulations or enforce compliance with
them. For example, in 2005, the Massachusetts Department of Public Health
approved sweeping new perinatal reg-
ulations that included a first-in-thenation requirement to discontinue
hospital distribution of commercial
discharge packs, but before the regulation could be implemented, it was retracted by the governor.
Public Reporting
Public reporting of quality metrics
also encourages hospitals to practice
evidence-based care, because patients
are attracted to hospitals that consistently show better performance. The
California WIC Association together
with the University of California Davis
Human Lactation Center have successfully used public reporting to drive
quality improvement.48 They publicly
reported the “gap” between any and
exclusive breastfeeding for each of the
state’s maternity hospitals. These data
were collected at the time of genetic
screening, and chart review suggests
that it is accurate (M.J. Heinig, written
communication, April 2009). In some
maternity centers, ⬎99% of breastfed
infants were receiving formula, clearly
far more than is medically indicated.
After the first public report, 12 hospitals were able to increase their exclusive breastfeeding rates by at least
50%, and 5 more than doubled their
rates.48 Some hospitals now handle infant formula the same way as medications: available only with a provider
order and locked in a medication
machine and strictly accounted for.
Other hospitals require parents to sign
a consent form before giving the infant
formula for nonmedical reasons, indicating that the parent understands the
risk to breastfeeding and the risk to
the infant’s health. This approach documents that the parent was educated
and made an informed decision. California’s success suggests that public
reporting of breastfeeding metrics in
general and the exclusivity gap in particular can drive quality improvement
in breastfeeding care.
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SPECIAL ARTICLES
Health Plan Employer Data and
Information Set
Health Plan Employer Data and Information Set (HEDIS) is another venue
for public reporting of breastfeeding
care quality. This data set is used by
⬎90% of America’s health plans to
measure performance on important
dimensions of care and service.49
Many health plans report HEDIS data to
employers or use their results to make
improvements in their quality of care
and service. Thus far, HEDIS has not
included breastfeeding measures. A
breastfeeding metric included as a
HEDIS measure may be helpful to initiate,
track, and measure ongoing efforts to
improve lactation care and services.
Pay for Performance
P4P plans offer additional financial
compensation to individual providers,
groups, or hospitals for meeting certain quality standards. Premier, Inc,
and the federal Centers for Medicaid
and Medicare Services recently completed a demonstration project of P4P
to hospitals and found that those that
received extra payment did modestly
better than those that were subjected
to public reporting alone.50
Although there have been some rare
insurance initiatives that reward
mothers who breastfeed, to our knowledge, there have been no public or private insurance initiatives in the United
States to reward hospitals or doctors
who have higher breastfeeding rates
among their patients. Incentives can
take the form of bonuses or withholds
and can be either outcome measures
(eg, hospital rates of exclusive breastfeeding) or process measures (eg, implementation of BFHI). In northern Italy, hospitals successfully increased in
breastfeeding rates after an initiative
of withholding 0.5% of payment for all
diagnosis-related groups for failure to
meet some specific breastfeeding process objectives set by the local health
PEDIATRICS Volume 124, Number 4, October 2009
authorities.51 Breastfeeding was 1 of
several quality objectives, and failure
to meet the other objectives resulted
in additional diagnosis-related group
withholdings.
Although P4P has been widely implemented in internal medicine, the literature on its effectiveness is mixed.
Many organizations have published
guidelines in response to criticisms,
including the AAP,52 the AAFP, the American Medical Association,53 and the
Joint Commission.54 The AAP recommends that measures be scientifically
valid and linked to evidence-based
best practices. Moreover, they should
be feasible so that data collection does
not cause undue burden on the clinician, patients, and families. They concur with AAFP recommendations to offer positive physician incentives and
support the physician–patient relationship. The American Medical Association recommends 4 principles in determining proper metrics for P4P: (1)
metrics should ensure quality of care;
(2) they should foster the relationship between patient and provider;
(3) they should used accurate and
fair data reporting; and (4) they
should provide fair and equitable
program incentives.53
Breastfeeding best practices may be
particularly well-suited to a P4P approach, as compared with some other
quality indicators. Insurers could offer
incentives for outcomes, such as the
exclusivity rate, or for structure and
process measures, such as BFHI certification. Hospitals could use P4P revenue to fund implementation of some
practices, such as ensuring adequate
staff training and paying fair-market
value for infant formula, and could
help move more hospitals to BabyFriendly status.
P4P incentives for breastfeeding support are likely to save money for insurers, especially in the long-term. Infants
who are formula fed have higher
health expenditures for certain acute
illness.2,3 Chronic pediatric diseases
are very costly, as are maternal malignancies and diabetes. Financial incentives may draw enough hospitals to apply for certification that a tipping point
will be reached, in which BFHI status
becomes competitive and achievable.
Because training in breastfeeding is
not uniform and because research
shows that many providers feel uncomfortable managing breastfeeding
problems,38 another quality metric
may consist of documenting continuing education for physicians and office
nurses specifically in breastfeeding.
Regional Collaboratives
In a regional collaborative, staff from
different hospitals work together to
learn from each other and meet common quality improvement goals at
their home institutions. Typically, key
stakeholders and “champions” learn
what their peers elsewhere are doing
and seek guidance about implementing change. Two studies have shown
that a local collaborative approach can
improve quality of care with various
quality issues.55,56
Mercier et al56 improved newborn preventive services in Vermont maternity
hospitals over 13 evidence-based parameters, including assessment of
breastfeeding adequacy and risk for
hyperbilirubinemia. The authors invited all maternity hospitals in the
state to work together to improve their
performance. During the intervention,
documentation of breastfeeding assessment improved from 49% to 81%.
Statewide collaborative approaches,
such as those taken in Vermont, are
likely to replicate success in other
states. Collaborative approaches depend on the will and funding of state
departments of public health or other
strong leaders to organize and spearhead them but ultimately use a “bottom up” approach to effect change
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e799
in individual institutions, achieving
buy-in and sustainability. If such efforts can increase breastfeeding,
then they may be cost-effective in
saving the state Medicaid dollars.
The approach in Northern Italy also
had collaborative elements and a
bottom-up approach, which may explain part of its success. Greater Los
Angeles has a collaborative around
breastfeeding in the 12 counties in
that region and has 18 Baby-Friendly
hospitals there. The MADLAC program in El Salvador was a national
collaborative with strong central
leadership that was associated with
significant increases in implementation of the Ten Steps and in duration
of exclusive breastfeeding.57
CONCLUSIONS
Breastfeeding is an important public
health issue. Most hospitals fall far
short of implementing evidence-based
best practices; as a result, current US
breastfeeding rates remain well below
Healthy People 2010 goals. Despite this
quality gap, there are limited incentives for hospitals or providers to implement best practices. Potential ap-
proaches to quality improvement
include education of hospital decisionmakers, recognition of excellence,
oversight by accrediting organizations, public reporting, P4P incentives,
and regional collaboratives. Widespread implementation of BFHI in the
United States would be most likely to
occur with strong centralized leadership, as in other successful countries.
Such efforts to improve quality of care
could affect both initiation and duration of breastfeeding, with substantial,
lasting benefits for maternal and child
health.
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January 27, 2009
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50. Lindenauer PK, Remus D, Roman S, et al. Public reporting and pay for performance in hospital
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397– 401
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hospitalization: a collaborative, hospital-based quality-improvement project. Pediatrics. 2007;
120(3):481– 488
57. Perez-Escamilla R. Effectiveness of MADLAC at Improving Breastfeeding Promotion and Counseling Indicators in Maternity Wards in El Salvador Published for Basic Support for Institutionalizing
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Hospital
Melissa Bartick, Alison Stuebe, Katherine R. Shealy, Marsha Walker and Laurence
M. Grummer-Strawn
Pediatrics 2009;124;e793-e802; originally published online Sep 14, 2009;
DOI: 10.1542/peds.2009-0430
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://www.pediatrics.org/cgi/content/full/124/4/e793
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2009 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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SPECIAL ARTICLES
Closing the Quality Gap: Promoting Evidence-Based
Breastfeeding Care in the Hospital
AUTHORS: Melissa Bartick, MD, MSc,a,b Alison Stuebe,
MD, MSc,c Katherine R. Shealy, MPH, IBCLC, RLC,d Marsha
Walker, RN, IBCLC,e and Laurence M. Grummer-Strawn,
PhDd
bDepartment of Medicine, Harvard Medical School, Boston,
Massachusetts; aDepartment of Medicine, Cambridge Health
Alliance, Cambridge, Massachusetts; cDepartment of Obstetrics
and Gynecology, Division of Maternal and Fetal Medicine,
University of North Carolina School of Medicine, Chapel Hill,
North Carolina; dDivision of Nutrition, Physical Activity, and
Obesity, Centers for Disease Control and Prevention, Atlanta,
Georgia; and eNational Alliance for Breastfeeding Advocacy,
Weston, Massachusetts
KEY WORDS
breastfeeding, hospitals, maternity, health care quality, quality
indicators, quality improvement, health care, infant, newborn
ABBREVIATIONS
CDC—Centers for Disease Control and Prevention
BFHI—Baby-Friendly Hospital Initiative
AAP—American Academy of Pediatrics
WHO—World Health Organization
UNICEF—United Nations Children’s Fund
P4P—pay for performance
mPINC—Maternity Practices in Infant Feeding and Care
NQF—National Quality Forum
AAFP—American Academy of Family Physicians
HEDIS—Health Plan Employer Data and Information Set
The findings and conclusions in this report are those of the
authors and do not necessarily represent views of the Centers
for Disease Control and Prevention.
www.pediatrics.org/cgi/doi/10.1542/peds.2009-0430
doi:10.1542/peds.2009-0430
Accepted for publication May 29, 2009
Address correspondence to Melissa Bartick, MD, MSc, Harvard
Medical School, Cambridge Health Alliance, 1493 Cambridge St,
Cambridge, MA 02139. E-mail: melissabartick@gmail.com
abstract
Evidence shows that hospital-based practices affect breastfeeding duration and exclusivity throughout the first year of life. However, a 2007
CDC survey of US maternity facilities documented poor adherence with
evidence-based practice. Of a possible score of 100 points, the average
hospital scored only 63 with great regional disparities. Inappropriate
provision and promotion of infant formula were common, despite evidence that such practices reduce breastfeeding success. Twenty-four
percent of facilities reported regularly giving non– breast milk supplements to more than half of all healthy, full-term infants. Metrics available for measuring quality of breastfeeding care, range from comprehensive Baby-Friendly Hospital Certification to compliance with
individual steps such as the rate of in-hospital exclusive breastfeeding.
Other approaches to improving quality of breastfeeding care include
(1) education of hospital decision-makers (eg, through publications,
seminars, professional organization statements, benchmark reports
to hospitals, and national grassroots campaigns), (2) recognition of
excellence, such as through Baby-Friendly hospital designation, (3)
oversight by accrediting organizations such as the Joint Commission
or state hospital authorities, (4) public reporting of indicators of the
quality of breastfeeding care, (5) pay-for-performance incentives, in
which Medicaid or other third-party payers provide additional financial
compensation to individual hospitals that meet certain quality standards, and (6) regional collaboratives, in which staff from different
hospitals work together to learn from each other and meet quality
improvement goals at their home institutions. Such efforts, as well as
strong central leadership, could affect both initiation and duration of
breastfeeding, with substantial, lasting benefits for maternal and child
health. Pediatrics 2009;124:e793–e802
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2009 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
PEDIATRICS Volume 124, Number 4, October 2009
Breastfeeding significantly predicts health outcomes for both mothers
and children. In 2007, the Agency for Healthcare Research and Quality
published a summary of systematic reviews and meta-analyses on
breastfeeding and health outcomes in developed countries and determined that early cessation of breastfeeding increases infants’ risks for
childhood obesity, gastroenteritis, necrotizing enterocolitis, leukemia,
otitis media, severe lower respiratory infections, sudden infant death
syndrome, and types 1 and 2 diabetes. Early cessation of breastfeeding
is linked with higher rates of maternal disease: breast and ovarian
cancers, type 2 diabetes, and postpartum depression.1 Infants who are
not breastfed incur up to $475 more health costs in the first year
compared with those who are exclusively breastfed for 3 months2
($671 in 2008 dollars3). Because many effects of breastfeeding are dose-
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e793
dependent, increasing breastfeeding duration can have a substantial impact
on public health.
Evidence shows that hospital practices
affect breastfeeding duration and exclusivity throughout the first year of
life,4–7 yet quality of breastfeeding care
in the United States is poor. In a 2007
Centers for Disease Control and Prevention (CDC) survey of ⬎80% of US
maternity facilities, the mean score
for implementation of evidence-based
breastfeeding care was 63 of 100 possible points.8 The 10 evidence-based
steps of the Baby-Friendly Hospital Initiative (BFHI) are known to increase
duration and exclusivity of breastfeeding when implemented, yet fewer than
3% of US hospitals are designated as
such.9 In some countries, all hospitals
are Baby-Friendly, and these countries
have strong government support, centralized leadership, and support from
the medical profession.10 The paucity
of US Baby-Friendly hospitals reflects
an endemic problem throughout
American health care: there is a significant gap between evidence-based recommendations and actual practice, as
detailed in the Institute of Medicine’s
2001 report, Crossing the Quality
Chasm.11 Closing this quality gap will
empower mothers to meet breastfeeding recommendations.
All major medical organizations, including the American Academy of Pediatrics (AAP) and the World Health
Organization (WHO), recommend 6
months of exclusive breastfeeding and
continued breastfeeding with appropriate complementary foods for at
least the first 1 to 2 years12–14; however, only ⬃12% of US infants are
breastfed exclusively for 6 months,
and only ⬃21% are breastfed for 12
months.15 Rates of any and exclusive
breastfeeding drop precipitously in
the first 2 weeks of life despite families’ frequent contact with the health
care system.
e794
BARTICK et al
The WHO/United Nations Children’s
Fund (UNICEF) Global Strategy for Infant and Young Child Feeding and the
American Public Health Association
urge immediate steps to improve
breastfeeding rates.14,16 The American
Public Health Association notes the
wide gap in the United States between
evidence-based care recommendations and current typical care. In this
article, we review data on quality of
breastfeeding care in US hospitals,
and we outline approaches to speeding adoption of best practices. We used
a PubMed search from January 1997
through April 2009 to identify Englishlanguage research done using the
term “breastfeed*” with the following
search terms: quality improvement,
quality management, performance incentives, and pay for performance
(P4P).
THE QUALITY GAP
Created in 1991, the BFHI is currently
the gold standard for evidence-based
breastfeeding care in hospitals (Table
1). Data continue to accumulate showing that adherence to the Ten Steps
predicts breastfeeding duration and
exclusivity, long after hospital discharge.4–7,17–19 Breastfeeding within
the first hour of life, exclusive breastfeeding in the hospital, and having a
written breastfeeding policy are the
steps generally found to have a the
greatest influence on success.4,18,20,21
The more steps that are practiced, the
higher duration and exclusivity of
breastfeeding at 2 months.4,6 DiGirolamo et al20 showed that breastfeeding
women who did not experience any of
the Ten Steps were 8 times more likely
to fail at breastfeeding by 6 weeks
compared with those who experienced
at least 6 of the steps. Individual steps
also affect outcomes. For example, 1
hospital-based intervention to reduce
formula supplementation of breastfed
newborns found that breastfeeding at
6 months increased to 87%, versus
66% beforehand.22
Despite strong evidence for the Ten
Steps, hospital compliance in the
United States is poor. The 2007 CDC
survey Maternity Practices in Infant
Feeding and Care (mPINC)8 sought to
survey all US maternity units, with
standardized questions based on their
implementation of the evidence-based
steps described in the BFHI. The CDC
survey addressed these issues from
the Ten Steps: (1) breastfeeding within
the first hour of life, (2) breastfeeding
on demand, (3) showing mothers how
to breastfeed, (4) prenatal education,
(5) absence of pacifiers, (6) rooming in
day and night, (7) absence of formula
supplementation without a medical
indication, (8) training of staff, (9)
breastfeeding support at discharge,
and (10) having a written breastfeeding policy that is conveyed to all staff.
TABLE 1 WHO/UNICEF Ten Steps to Successful Breastfeeding
1. Have a written breastfeeding policy that is routinely communicated to all health care providers.
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 1 h of birth.
5. Show mothers how to breastfeed and how to maintain lactation, even if they should be separated
from their infants.
6. Give newborn infants no food or drink other than breast milk, unless medically indicated.a
7. Practice rooming in: allow mothers and infants to remain together 24 h/d.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups, and refer mothers to them on discharge
from the hospital or clinic.
a The hospital or birthing site must pay fair-market price for all formula and infant feeding supplies that it uses and cannot
accept free or heavily discounted formula and supplies.
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SPECIAL ARTICLES
On the basis of a standard script, 1 respondent from each maternity center
answered the survey. To encourage
candid responses, respondents were
assured that their data would not be
publicly reported. Instead, each facility
was given a report comparing its results with benchmarks for other hospitals of similar size nationally and
with other hospitals in the same state.
Of a possible score of 100 points, the
average hospital scored only 63, with
the mean total scores ranging from 48
(Arkansas) to 81 (New Hampshire and
Vermont). Great regional disparities
were found, with the southern states
performing worse than the northeastern and western regions. Although
88% of facilities reported that they
taught most mothers techniques of
breastfeeding, practices that are
known to be detrimental to breastfeeding were common. For example, 65% of
facilities advised women to limit the
duration of suckling at each breastfeeding, and 45% reported giving pacifiers to healthy term infants.
Inappropriate provision and promotion of infant formula were common,
despite evidence that such practices
reduce breastfeeding success.4–6,23
Twenty-four percent of facilities reported regularly giving non– breast
milk supplements to more than half of
all healthy, term infants. These results
are consistent data from the Infant
Feeding Practices Study II, which found
that 41% of breastfed infants are supplemented with infant formula in the
hospital.15,24,25 Inappropriate supplementation has been associated with
shorter duration of breastfeeding in
multiple studies,7,20,26,27and it also incurs health risks that are associated
with nonexclusive breastfeeding.1,28
Moreover, the majority of facilities reported that they participate in formula
company marketing programs. Multiple studies have shown that formula
marketing packs reduce duration of
PEDIATRICS Volume 124, Number 4, October 2009
exclusive breastfeeding.23,29,30 Nonetheless, fully 70% of facilities reported giving commercial discharge packs that
contain infant formula to breastfeeding mothers. A separate study found
that 93% of hospitals give out any commercial discharge packs to at least
some mothers.31
The mPINC study results provide the
first national, systematically collected
data on the substantial gap between
best practices and routinely provided
maternity care. Underuse of these
evidence-based practices leads to premature weaning, with adverse consequences for maternal and infant
health.
BARRIERS TO QUALITY
IMPROVEMENT
Changes to Clinical Routine
Optimizing breastfeeding support will
require cultural changes in patterns of
care in hospitals. For example, on a
busy postpartum unit, it is much easier to offer a bottle than to diagnose
and resolve breastfeeding problems.
Similarly, removing the infant from the
mother’s room to perform a variety of
procedures (eg, photographs, newborn screening, examinations) may be
convenient for a busy hospital, but this
practice interferes with the mother’s
ability to breastfeed on demand. These
issues are substantial barriers to implementing Baby-Friendly practices, as
a national survey showed: hospitals reported that the most difficult steps
to implement were steps 6 (no supplements), 2 (staff training), and 7
(rooming in).
Formula Marketing
Doing away with hospital-based marketing of infant formula and paying fair
market value for formula have posed a
particular barriers to implementing
evidence-based care.19 Typically, most
US hospitals receive their well-infant
formulas free of charge from brand-
name manufacturers and in return are
expected to distribute commercial discharge packs that market that brand,
thereby implying endorsement from
the hospital. In Baby-Friendly hospitals, the cost of purchasing formula is
passed on in the room and board
charge, the same way food for other
patients is handled.
Safety-net hospitals such as Boston
Medical Center and San Francisco General Hospital have been able to achieve
Baby-Friendly status and pay for formula. Implementing BFHI also decreases costs of unused products
such as pacifiers, nipples, and discharge packs and saves on labor costs
and storage space required for discharge packs.32 Formula companies
have been known to overestimate
vastly the amount of formula that a
hospital requires, grossly inflating
projected costs.32 If hospitals wait to
pay for formula until they have implemented the other steps, then the need
for purchased formula is reduced.32,33
It may be helpful for hospital leaders to
know that severing ties from the formula industry is consistent with recent recommendations that the
health professions distance themselves from industry to avoid conflicts of interest that could compromise patient care.34,35
Attitudes and Beliefs
To implement elements of the BFHI,
supporters must negotiate varying attitudes and beliefs about breastfeeding. Norms for infant feeding have
changed dramatically in the past 3 decades. Some senior staff members,
many of whom have formula-fed their
own children, firmly believe that formula feeding is substantially equivalent to breastfeeding.36 A recent study
found that 45% of pediatricians surveyed agreed with the statement that
breastfeeding and formula feeding are
equally acceptable methods for feed-
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e795
ing infants.37 Others view infant feeding as a consumer choice, not a modifiable health behavior, and they are
reluctant to “push” mothers to breastfeed. Efforts to change breastfeeding
practices will have to address this tension between reinforcing medical recommendations and respecting patient
autonomy. Moreover, many providers
argue that maternity care has little or
no impact on breastfeeding success,
and they will need to be convinced that
practice changes matter. Finally, providers may lack the skills to address
basic breastfeeding needs, because
breastfeeding training in medical and
nursing education is limited, at best.38
Achieving 18 to 21 hours of training for
perinatal nurses has been described
as a significant barrier to achieving
Baby-Friendly certification, although
this is the minimum recommendation.19 This results in clinicians’ leaving
simple breastfeeding problems unresolved or relegating them to lactation
consultants, whose expertise is better
used for more complex issues.
METRICS FOR QUALITY
ASSESSMENT
Several metrics are available for measuring quality of breastfeeding care,
ranging from comprehensive BFHI certification to compliance with individual
steps, such as paying market value for
infant formula. Other metrics include
the distribution of formula company
discharge packs, mPINC scores, presence of an evidence-based written
breastfeeding policy, and the rate of
in-hospital exclusive breastfeeding
among breastfeeding infants. Each
metric has its advantages and disadvantages (Table 2).
The rate of in-hospital exclusive
breastfeeding among breastfed infants is especially promising for several reasons. First, it can be measured
as part of existing infrastructure for
collecting neonatal data, via genetic
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BARTICK et al
screening surveys or by modifying and
implementing the US Standard Certificate of Live Birth to collect this information. Second, to score high on exclusive breastfeeding, a hospital would
need to have successfully implemented many of the other Ten Steps
that are known to decrease the use of
supplementation and improve breastfeeding success, such as rooming in,
breastfeeding in the first hour of life,
and curtailment of formula marketing.
Finally, in-hospital exclusivity is patient centered, because its association
with improved breastfeeding duration
helps women meet their own breastfeeding goals. The National Quality Forum (NQF) recently endorsed the rate
of in-hospital exclusive breastfeeding
as a consensus standard for perinatal
care.39
APPROACHES TO IMPROVING
QUALITY OF CARE
To date, there have been few published
reports on approaches to improving
quality of care around breastfeeding.
Potential approaches include education of hospital decision-makers, recognition of excellence, oversight by
accrediting organizations, public reporting, P4P incentives, and regional
collaboratives.
Education of Hospital
Decision-Makers
There are a variety of opportunities to
educate and motivate key hospital
decision-makers to adopt evidencebased practices. Lactation consultants
and nongovernmental organizations
are often contracted by hospitals to assist with quality improvement around
breastfeeding. Regional meetings or a
summit of key leaders could help to
educate stakeholders and improve
networking opportunities and buy-in,
and these sessions could include training on implementation of best practices. Sharing peer-reviewed publications about the evidence for the Ten
Steps and about implementing them
can be influential, as can Web-based
resources. Often, an individual who
already works in the hospital leads
this type of educational effort, with
the regional effort from an outside
organization.
The mPINC survey was explicitly designed to educate decision-makers
and stimulate hospitals to implement
evidence-based best practices. The
CDC shared survey results with all
2690 participating hospitals and birth
centers, assigning each facility a set of
scores that compared their own practices with evidence-based practices,
highlighting those that are most problematic. The individualized reports
compared each hospital’s scores with
those in other facilities across their
state and the country and with those
of a similar size. These “benchmark
reports” included references to the
scientific literature explaining how
each practice affects breastfeeding
success. The CDC plans to repeat the
survey every 2 years so that hospitals can engage in continuous quality
improvement.
Grassroots movements can also serve
as a catalyst to draw the attention of
decision-makers around a specific
hospital practice. A growing body of evidence shows that commercial discharge packs are associated with decreased exclusive breastfeeding.29,40,41
The Ban the Bags campaign (http://
banthebags.org) has drawn attention
to the risks of hospital-based formula
promotion, attracting national press
coverage and encouraging hospitals to
reevaluate this practice.8,42 In addition,
state breastfeeding coalitions and
departments of public health have
awarded certificates to “bag-free” hospitals, helping incentivize efforts to improve quality of care.
Strong statements from professional
organizations can also encourage hospitals to adopt specific practices. The
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PEDIATRICS Volume 124, Number 4, October 2009
TABLE 2 Metrics That Can Be Used for Public Reporting and/or P4P Incentives and Related Advantages and Disadvantages
Facility Metric (Measure)
Method
Breastfed infants who receive 1. Feeding status as indicated in newborn
genetic screening or birth certificate
only breast milk during the
documentation 1. Rates of EBF in hospital
maternity stay (proportion
predict overall breastfeeding duration
of breastfed infants)
2. Infant formula dispensed from Pyxis
system
3. Prevalence determined from chart audit/
review
Facility designation by Baby-Friendly USA
mPINC survey score (score
out of 100)
Facility score based on responses to CDC
survey
Written breastfeeding policy
including core evidencebased breastfeeding
practices (yes/no)
Distributes formula company
discharge packs (yes/no)
Facility documentation of written policy
Price paid for infant formula
(price per unit purchased
relative to fair-market
price or 0 关received free of
charge from
manufacturer兴)
Facility self-report
Facility self-report
EBF indicates exclusive breastfeeding.
Disadvantages
2. High EBF rates reflect presence of
many of the Ten Steps
2. In states without current data collection
infrastructure, adoption would require either
amendments to the birth certificate or genetic
screening forms or periodic chart audit/review
3. Generally appropriately excludes those 3. Political and economic influence from the infant
formula industry could make establishment of
for whom breastfeeding is
Pyxis dispensation and tracking of infant formula
contraindicated (eg, HIV positive,
more difficult
dependent on drugs of abuse),
allowing for comparability across
facilities and patient populations
1. Requires no new assessment
1. Less than 3% of US hospitals are currently
infrastructure
designated Baby-Friendly, so it is not considered a
normative standard yet
2. Specifically identifies compliance with 2. Designation does not recognize partial
implementation
evidence-based practice and care
process measures
3. Ensures standardized compliance with
the Ten Steps
4. Status is widely regarded and
recognized
Provides a national, standard measure of 1. Because individual facility scores are confidential,
hospital practices and care processes
disclosure would be voluntary
included in the Ten Steps
2. Disclosure could affect accuracy of future survey
results
3. Scores are based on 1 individual’s report of
typical practices and care processes at each
hospital and have not been externally validated
Assessment is straightforward via either Written policies may not reflect actual practice;
there may be issues with accurate reporting
inquiry to facility or use of existing
mPINC data
1. Assessment is straightforward via
inquiry to facility
2. Reflects base level of commitment to
supporting breastfeeding
3. Reflects independence from
inappropriate marketing to patients
1. Assessment is straightforward via
review of purchase contracts
2. Reflects a commitment to supporting
breastfeeding
3. Reflects reduced influence from infant
formula manufacturers
Comments
1. The NQF has endorsed using EBF in the hospital as
a quality measure in part on the basis of success
in California of using this metric
Addresses only 1 of the important barriers to
breastfeeding
Definition of “fair-market price” may be difficult to
establish
2. This metric could easily be assessed and
adopted by HEDIS and was recently adopted by
Joint Commission
Federal oversight and/or a system for recognizing
partial implementation of the Ten Steps may be
necessary for hospitals to be able to pursue
financial incentives to implementing the Ten
Steps
Facilities’ mPINC scores could provide a baseline
for regional collaboratives to use to assess
progress by using quality improvement
strategies
The Academy of Breastfeeding Medicine has a
freely available model policy and provides a
template for hospitals to implement evidencebased practices
Facilities that have received awards for becoming
“Bag-Free Hospitals” have improved visibility
and recognition of the adverse effects of direct
formula marketing to patients
Growing awareness of the impact of “free” or
discounted brand-name pharmaceuticals has
drawn attention to ethical concerns about
hospital marketing of branded products
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SPECIAL ARTICLES
Baby-Friendly status (yes/no)
Advantages
1. Feasibility of data collection varies
across states
AAP policy statement on breastfeeding13 outlines appropriate peripartum
procedures to facilitate the initiation
of breastfeeding, as does the statement from the American Academy of
Family Physicians (AAFP).12 The Academy of Breastfeeding Medicine has developed a model hospital policy to
guide hospitals.43
Recognition of Excellence
Several recognition programs honor
hospitals that practice evidence-based
breastfeeding care. The oldest and
most rigorous form of recognition is
Baby-Friendly designation. To qualify
as Baby-Friendly, a facility must apply
for a certificate of intent, implement
the Ten Steps, and undergo a site visit.
Baby-Friendly remains the gold standard because of its strong evidence
base and its origins from WHO and
UNICEF. Baby-Friendly status is highly
regarded by health professionals but
is largely unknown to the general
public.
Hospitals often are able to achieve the
Ten Steps by using standard quality
management techniques, such as the
“plan-do-check-act” model.44 Implementing certain practices, such as
skin-to-skin contact immediately after
birth, and increased staff training may
allow other steps to fall into place
more readily.
In addition to BFHI, several states have
developed recognition programs for
excellence in breastfeeding care. The
Texas Department of State Health Services has its own recognition program,
the “Texas Ten Step.” This program is
based on the BFHI, but compliance is
self-reported, and the program does
not require hospitals to purchase formula at fair-market value. The program offers staff training and encourages hospitals ultimately to obtain the
BFHI designation. As of April 2009, 68 of
190 hospitals had the Texas Ten Step
certification,45 but only 2 Texas hospie798
BARTICK et al
tals are designated as Baby-Friendly9
and only 6 have reported eliminating
commercial discharge packs.46 Other
state departments of health, such as
Oregon’s, have publicly recognized
hospitals that have eliminated commercial discharge bags, and Massachusetts is now following suit by recognizing bag-free hospitals and
other improvements in breastfeeding outcomes.
Oversight by Accrediting
Organizations
Accrediting organizations have considerableleverageinmodifyinghospital practices. The Joint Commission,
which accredits most US hospitals,
has set quality measures in many areas, with many more expected to follow. All of these metrics are publicly
reported and the subject of considerable attention by hospital administrators nationwide. Until recently, no
quality metric related to breastfeeding
was available from the Joint Commission. However, on July 20, 2009, the
Joint Commission announced that it
was adding ‘exclusive breast milk feeding’ as a new hospital Core Measure
for perinatal care, effective April
2010.47 It is likely that this new Core
Measure could have a tremendous impact on hospital practice and breastfeeding outcomes. It is likely that adding a breastfeeding metric, such as the
exclusivity rate, to the Joint Commission Core Measures could have a tremendous impact on hospital practice
and breastfeeding outcomes.
State regulations, promulgated by
state health departments, also represent an opportunity to improve breastfeeding practices; however, often states
do not have the resources or the political power to implement strong regulations or enforce compliance with
them. For example, in 2005, the Massachusetts Department of Public Health
approved sweeping new perinatal reg-
ulations that included a first-in-thenation requirement to discontinue
hospital distribution of commercial
discharge packs, but before the regulation could be implemented, it was retracted by the governor.
Public Reporting
Public reporting of quality metrics
also encourages hospitals to practice
evidence-based care, because patients
are attracted to hospitals that consistently show better performance. The
California WIC Association together
with the University of California Davis
Human Lactation Center have successfully used public reporting to drive
quality improvement.48 They publicly
reported the “gap” between any and
exclusive breastfeeding for each of the
state’s maternity hospitals. These data
were collected at the time of genetic
screening, and chart review suggests
that it is accurate (M.J. Heinig, written
communication, April 2009). In some
maternity centers, ⬎99% of breastfed
infants were receiving formula, clearly
far more than is medically indicated.
After the first public report, 12 hospitals were able to increase their exclusive breastfeeding rates by at least
50%, and 5 more than doubled their
rates.48 Some hospitals now handle infant formula the same way as medications: available only with a provider
order and locked in a medication
machine and strictly accounted for.
Other hospitals require parents to sign
a consent form before giving the infant
formula for nonmedical reasons, indicating that the parent understands the
risk to breastfeeding and the risk to
the infant’s health. This approach documents that the parent was educated
and made an informed decision. California’s success suggests that public
reporting of breastfeeding metrics in
general and the exclusivity gap in particular can drive quality improvement
in breastfeeding care.
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SPECIAL ARTICLES
Health Plan Employer Data and
Information Set
Health Plan Employer Data and Information Set (HEDIS) is another venue
for public reporting of breastfeeding
care quality. This data set is used by
⬎90% of America’s health plans to
measure performance on important
dimensions of care and service.49
Many health plans report HEDIS data to
employers or use their results to make
improvements in their quality of care
and service. Thus far, HEDIS has not
included breastfeeding measures. A
breastfeeding metric included as a
HEDIS measure may be helpful to initiate,
track, and measure ongoing efforts to
improve lactation care and services.
Pay for Performance
P4P plans offer additional financial
compensation to individual providers,
groups, or hospitals for meeting certain quality standards. Premier, Inc,
and the federal Centers for Medicaid
and Medicare Services recently completed a demonstration project of P4P
to hospitals and found that those that
received extra payment did modestly
better than those that were subjected
to public reporting alone.50
Although there have been some rare
insurance initiatives that reward
mothers who breastfeed, to our knowledge, there have been no public or private insurance initiatives in the United
States to reward hospitals or doctors
who have higher breastfeeding rates
among their patients. Incentives can
take the form of bonuses or withholds
and can be either outcome measures
(eg, hospital rates of exclusive breastfeeding) or process measures (eg, implementation of BFHI). In northern Italy, hospitals successfully increased in
breastfeeding rates after an initiative
of withholding 0.5% of payment for all
diagnosis-related groups for failure to
meet some specific breastfeeding process objectives set by the local health
PEDIATRICS Volume 124, Number 4, October 2009
authorities.51 Breastfeeding was 1 of
several quality objectives, and failure
to meet the other objectives resulted
in additional diagnosis-related group
withholdings.
Although P4P has been widely implemented in internal medicine, the literature on its effectiveness is mixed.
Many organizations have published
guidelines in response to criticisms,
including the AAP,52 the AAFP, the American Medical Association,53 and the
Joint Commission.54 The AAP recommends that measures be scientifically
valid and linked to evidence-based
best practices. Moreover, they should
be feasible so that data collection does
not cause undue burden on the clinician, patients, and families. They concur with AAFP recommendations to offer positive physician incentives and
support the physician–patient relationship. The American Medical Association recommends 4 principles in determining proper metrics for P4P: (1)
metrics should ensure quality of care;
(2) they should foster the relationship between patient and provider;
(3) they should used accurate and
fair data reporting; and (4) they
should provide fair and equitable
program incentives.53
Breastfeeding best practices may be
particularly well-suited to a P4P approach, as compared with some other
quality indicators. Insurers could offer
incentives for outcomes, such as the
exclusivity rate, or for structure and
process measures, such as BFHI certification. Hospitals could use P4P revenue to fund implementation of some
practices, such as ensuring adequate
staff training and paying fair-market
value for infant formula, and could
help move more hospitals to BabyFriendly status.
P4P incentives for breastfeeding support are likely to save money for insurers, especially in the long-term. Infants
who are formula fed have higher
health expenditures for certain acute
illness.2,3 Chronic pediatric diseases
are very costly, as are maternal malignancies and diabetes. Financial incentives may draw enough hospitals to apply for certification that a tipping point
will be reached, in which BFHI status
becomes competitive and achievable.
Because training in breastfeeding is
not uniform and because research
shows that many providers feel uncomfortable managing breastfeeding
problems,38 another quality metric
may consist of documenting continuing education for physicians and office
nurses specifically in breastfeeding.
Regional Collaboratives
In a regional collaborative, staff from
different hospitals work together to
learn from each other and meet common quality improvement goals at
their home institutions. Typically, key
stakeholders and “champions” learn
what their peers elsewhere are doing
and seek guidance about implementing change. Two studies have shown
that a local collaborative approach can
improve quality of care with various
quality issues.55,56
Mercier et al56 improved newborn preventive services in Vermont maternity
hospitals over 13 evidence-based parameters, including assessment of
breastfeeding adequacy and risk for
hyperbilirubinemia. The authors invited all maternity hospitals in the
state to work together to improve their
performance. During the intervention,
documentation of breastfeeding assessment improved from 49% to 81%.
Statewide collaborative approaches,
such as those taken in Vermont, are
likely to replicate success in other
states. Collaborative approaches depend on the will and funding of state
departments of public health or other
strong leaders to organize and spearhead them but ultimately use a “bottom up” approach to effect change
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e799
in individual institutions, achieving
buy-in and sustainability. If such efforts can increase breastfeeding,
then they may be cost-effective in
saving the state Medicaid dollars.
The approach in Northern Italy also
had collaborative elements and a
bottom-up approach, which may explain part of its success. Greater Los
Angeles has a collaborative around
breastfeeding in the 12 counties in
that region and has 18 Baby-Friendly
hospitals there. The MADLAC program in El Salvador was a national
collaborative with strong central
leadership that was associated with
significant increases in implementation of the Ten Steps and in duration
of exclusive breastfeeding.57
CONCLUSIONS
Breastfeeding is an important public
health issue. Most hospitals fall far
short of implementing evidence-based
best practices; as a result, current US
breastfeeding rates remain well below
Healthy People 2010 goals. Despite this
quality gap, there are limited incentives for hospitals or providers to implement best practices. Potential ap-
proaches to quality improvement
include education of hospital decisionmakers, recognition of excellence,
oversight by accrediting organizations, public reporting, P4P incentives,
and regional collaboratives. Widespread implementation of BFHI in the
United States would be most likely to
occur with strong centralized leadership, as in other successful countries.
Such efforts to improve quality of care
could affect both initiation and duration of breastfeeding, with substantial,
lasting benefits for maternal and child
health.
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