Exclusive breastfeeding, Infant care, Perinatal care, Quality improvement.



  1. Magri, Eileen P. MSN, RN, NE-BC
  2. Hylton-McGuire, Karen MS, RNC-NIC, IBCLC, RLC


Abstract: This article describes the process of changing the care delivery model for maternity practice in a New York State Regional Perinatal Center to support exclusive breastfeeding, defined as providing nothing other than human milk feedings. Barriers exist in hospitals that inhibit exclusive breastfeeding of newborns at the time of discharge and fail to meet the recommendations outlined by the World Health Organization and New York State Department of Health. All aspects of mother/baby care were evaluated to meet the recommendations and increase exclusive breastfeeding. Transforming the care delivery model for mothers and babies began in 2010 with an invitation to participate in the New York State Breastfeeding Quality Improvement in Hospitals Learning Collaborative. Twelve hospitals were selected to participate with the following objectives: increase exclusive breastfeeding; improve hospital breastfeeding policies, practices, and systems that are consistent with New York State hospital regulations, laws and recommended best practices; increase staff skills and knowledge of breastfeeding and lactation support through education; empower, educate, and support new mothers to successfully breastfeed and change the culture and social norm relative to breastfeeding. The transformation of the care delivery model resulted in an increase in exclusive breastfeeding from 6% to 44%.


Article Content

Evidence supports the short-term and long-term benefits of exclusive breastfeeding for mother and child (American Academy of Pediatrics [AAP], 2012; Bartick & Reinhold, 2010; Stuebe & Schwarz, 2010). Skin-to-skin contact and successful latch to the breast by the newborn during the first hours after birth influence a mother's ability to breastfeed successfully (Brown, Raynor, & Lee, 2011; Declercq, Labbok, Sakala, & O'Hara, 2009). In 2007, 2009 and 2011, the Centers for Disease Control (CDC) conducted the CDC National Maternity Practices in Infant Nutrition and Care (mPINC) survey to characterize United States maternity practices related to breastfeeding (DiGirolamo et al., 2008; Perrine et al., 2011). Hospitals were evaluated for practices known to enhance exclusive breastfeeding within the hospital setting and after discharge (Murray et al., 2007). Each state was evaluated on their compliance with the World Health Organization (WHO) recommendations for breastfeeding initiation and support in the hospital (WHO, 1998, 2009) and received a report card from the CDC. Results of the CDC survey determined that barriers exist in hospitals that inhibit exclusive breastfeeding of newborns at the time of discharge and fail to meet the recommendations of The Ten Steps toSuccessful Breastfeeding outlined by WHO and the United Nations Children's Fund (UNICEF) in 1998 and updated in 2009 (DiGirolamo, Manninen, et al., 2008).

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We wanted to change the maternity care delivery model at Winthrop University Hospital to support exclusive breastfeeding. We used the Model for Improvement framework and Plan-Do-Study-Act (P-D-S-A) cycle methodology to remove existing barriers and to implement The Ten Steps toSuccessful Breastfeeding (Langley et al., 2009; WHO, 1998). This method includes applying process changes, evaluating effectiveness of change through feedback, and monitoring progress to sustain improvement.


The catalyst to transform the care delivery model for mothers and newborns began in June 2010 with an invitation to participate in the New York State (NYS) Breastfeeding Quality Improvement in Hospitals (BQIH) Learning Collaborative. The BQIH Learning Collaborative sought to implement the CDC mPINC survey recommendations for NYS which included (1) examine NYS regulations for maternity facilities, evaluate their evidence base and revise if necessary (New York State Department of Health Rules and Regulations, 2005); (2) sponsor a NYS wide summit of key decision-making staff at maternity facilities to highlight the importance of evidence-based practices for breastfeeding; (3) pay for hospital staff across NYS to participate in 18-hour courses in breastfeeding; (4) establish links among maternity facilities and community breastfeeding support networks in NYS; and (5) integrate maternity care into quality improvement efforts. The BQIH Learning Collaborative was sponsored through a partnership between the New York State Department of Health (NYSDOH) Obesity Prevention Program and the National Initiative for Children's Healthcare Quality (NICHQ). Twelve hospitals with varying characteristics and exclusive breastfeeding rates participated in the project. Objectives of the project were (1) increase exclusive breastfeeding; (2) improve hospital breastfeeding policies, practices, and systems; (3) increase staff skills and knowledge of breastfeeding support through education; (4) empower, educate, and support new mothers to successfully breastfeed; and (5) change the culture and social norm relative to breastfeeding.



This quality project took place in a NYSDOH Designated Regional Perinatal Center with 4,500 annual births. Within the facility, there is a L&D unit, which consists of obstetrical (OB) triage, labor, delivery, and recovery (LDR) rooms, surgical suites and OB postanesthesia care unit (PACU), and high-risk antepartum, postpartum, newborn nursery, and level III NICUs. This project focused on mother/baby care in L&D, postpartum, and the newborn nursery. The nursing staff involved in this project included 59 labor and delivery registered nurses (RNs) and 67 postpartum/nursery RNs. The project was supported by senior hospital leaders and the physician Chairpersons of the departments of Pediatrics and Obstetrics & Gynecology.



An evaluation of hospital systems and staff knowledge related to breastfeeding revealed failure to meet criteria as defined in The Ten Steps to Successful Breastfeeding supported by AAP (2012) and WHO (1998, 2009). A comprehensive, multidisciplinary team was formed to evaluate current processes and potential barriers that inhibit exclusive breastfeeding. Team members were selected based on knowledge of hospital systems and commitment to change. The first area evaluated was newborn care practices in L&D. Routine practice separated mothers and babies at approximately 1 hour of life. Newborns were transferred to the nursery by the staff where routine transition care was performed while mother recovered in L&D. This process kept mothers and babies separated for more than 6 hours on average. The next area of focus was the postpartum unit. Newborn orders were preprinted with feeding orders for both breast milk and formula. For convenience, physicians checked both boxes for breastfeeding newborns. The practice encouraged supplementation of breastfeeding newborns. Modified mother/baby care was practiced, encouraging rooming-in during the day and returning babies to the nursery at night. Mother and baby were cared for by two different staff members. Nighttime feedings occurred in the newborn nursery. Breastfeeding babies were brought out of the nursery to be fed by the mother only upon request, otherwise the newborn was supplemented with formula. This practice was encouraged by both the physician and nursing staff.


Tests of Change

The team prioritized changes that could be accomplished quickly and sustained. The selected changes were (1) establish skin-to-skin mother/baby contact in L&D after all births including formula fed babies; (2) increase time babies spent in mothers' rooms on postpartum unit; (3) revise newborn order sets; (4) revise newborn flow sheet; (5) reassign nursery RNs to L&D to assess transition and admit newborns; (6) keep mother and baby together; and (7) eliminate fragmentation of care by implementing mother/baby care on the postpartum unit.


The initial test of change focused on newborn care in L&D. Staff education regarding skin-to-skin mother/baby contact had begun a few months prior to joining the BQIH Learning Collaborative. According to Walters, Boggs, Ludington-Hoe, Price, and Morrison (2007), placing newborns skin-to-skin immediately after birth has been shown to provide physiologic benefits to both mother and baby. The goal was to place all babies skin-to-skin in the LDR, successfully latching and breastfeeding within 1 hour for vaginal births and 2 hours for cesarean births. One nurse was selected to objectively observe workflow during a birth to identify barriers that would prevent staff from placing babies skin-to-skin. Obtaining the birthweight was quickly identified as a barrier. The admitting department required the birthweight to admit the newborn to the hospital system and to generate the medical record number needed for all care to be rendered. After meeting with representatives from the admitting and information technology departments, the process was redesigned to forgo the birthweight until a later time. Admitting the newborn to the hospital system was accomplished using the mother's name, pediatrician name, sex of the baby, and date and time of birth. When this barrier was removed, the skin-to-skin test of change was reinitiated. Staff acclimated to the change quickly and adopted the practice for cesarean births. Mothers were educated during the admission process and responded favorably. This process change was deemed a success by the team within 1 month of implementation.


The next test of change focused on the postpartum unit. The team revised newborn admission orders to reflect two separate order sets. One set was for formula-fed babies and the other set was for breastfed babies. The option for formula supplementation was removed from the breastfeeding newborn admission orders. Upon admission the mother states her feeding preference as either breast or formula that would generate a specific order set to support her preference. The staff is now required to inform the mother before supplementing a breastfeeding newborn with formula. In addition, a physician order for supplementation must be obtained before providing formula. When breastfeeding mothers request formula supplementation, nurses provide education to inform the mother of the potential effects of nonmedically necessary supplementation on breastfeeding. Placing bottles of formula in the bassinet when the newborn was brought to the mother's room was discontinued. Instead, formula was placed in the Pyxis Inventory Supply Station and could be accessed by patient name if needed. Giving gift packs provided by the formula companies to mothers upon discharge was eliminated. The gift packs contained formula samples and coupons for formula products that subliminally undermined a mother's decision to breastfeed her newborn (Kaplan & Graff, 2008; United States Accountability Office, 2006). All other marketing materials provided by formula companies were also removed from the unit and replaced with hospital-specific items.


Newborns rooming-in with their mothers have been shown to be effective in promoting successful breastfeeding (AAP, 2012). The nightly routine practice was to return all newborns to the nursery at 10 o'clock. The test of change to increase rooming-in generated much opposition. Staff opinion regarding rooming-in was negative. Most of the staff felt the facility layout and lack of private maternity rooms would deter the mother's decision to have her baby room-in. The current practice did not permit the mother to have the option to keep her baby in the room all night. The team opted to approach this test of change passively. The nightly routine returning all babies to the nursery at 10 o'clock was eliminated. Instead, babies were brought to the nursery at night when requested by the mother. This passive approach proved successful and the concerns of the staff did not materialize.


Mothers and newborns were still being separated after the initial skin-to-skin time in L&D. The next test of change required careful consideration and innovation. The newborn nursery staff assigned to transition care of the healthy newborn would be relocated to L&D instead of bringing the babies to the nursery. A core group of nursery staff RNs who were interested in transition care in L&D were identified. The nursery staff spent time in the LDR observing births to determine how to incorporate the transition process in L&D. After several P-D-S-A cycles, the nursing staff determined newborn transition care could be performed in the LDR for healthy babies and in the OB PACU for cesarean and high-risk births. Any newborn requiring a higher level of care in the NICU was excluded. This test of change was the most challenging. The process took 6 months to evaluate, to educate the nursing staff and to complete the conversion. The role of the nursery nurse included newborn assessment, administration of mandated medications, and supporting successful latch and breastfeeding in the LDR or OB PACU. Babies were transferred in their mother's arms and admitted to the postpartum unit together eliminating another separation point.


The final test of change culminated the project by changing the care delivery model on the postpartum unit to mother/baby care. This change occurred simultaneously with the implementation of the transition nurse in the LDR and OB PACU. The postpartum and newborn nursery staff nurses were educated on mother/baby care. Each nurse would be responsible for the care of the mother and baby couplet. The newborn nursery continued to be staffed by an RN and ancillary staff for continuity with the physicians; however, the transition care nursery was unnecessary because the care was provided in the LDR or OB PACU. No additional staff was required to implement these changes.


While the tests of change cycles were in progress, all nurses on the postpartum unit were given complimentary access to an online 18-hour breastfeeding course from the BQIH Learning Collaborative. As each change became standard practice, the breastfeeding policies and procedures were revised.


Data Collection

Fifteen data collection points were preestablished for each of the 12 hospitals participating in the BQIH Learning Collaborative (Table 1). Monthly audits were conducted (n = 50) at each hospital and submitted to an extranet Web site supported through the Institute for Healthcare Improvement. Based on birth volume at our hospital (n = 4,500), the sample of healthy newborns was selected using every fifth chart methodology, rotating the starting point each month.

Table 1 - Click to enlarge in new windowTable 1. Data Collection


As a participating member of the BQIH Learning Collaborative, goals were set by the NYSDOH and NICHQ teams for each of the 12 hospitals. Each hospital's results were shared with all members of the BQIH Learning Collaborative and reported during scheduled learning sessions throughout the project time frame. Individual hospitals also set internal goals. Each successful test of change made a directional positive impact. Baseline data were collected in June 2010 before goal setting. Process improvement activities began in August 2010. Placing newborns skin-to-skin within 1 hour for vaginal births and 2 hours for cesarean births reached a 90% threshold and has been sustained. Rooming-in increased from 0% to over 70% and exclusive breastfeeding has increased from 6% to 44% by month 24 (May 2012) (Figure 1). The maternity nursing staff (100%) completed The Ten Steps to Successful Breastfeeding On-line Course within 12 months. Since then, the online course has been included as basic orientation for new nurses.

Figure 1 - Click to enlarge in new windowFigure 1. Results


For the last 30 years, the importance of breastfeeding has been addressed in multiple forums. Evidence to support exclusive breastfeeding continues to mount (Stuebe & Schwarz, 2010). C. Everett Koop, a former Surgeon General, convened the first breastfeeding workshop in 1987 to address breastfeeding deficiencies across the country (United States Department of Health and Human Services, 2011a, 2011b). The WHO published The Ten Steps to Successful Breastfeeding (1998). The AAP (2012) endorsed exclusive breastfeeding. Healthy People 2000, 2010, and 2020 have set goals for exclusive breastfeeding (Heck & Klein, 1997; United States Department of Health and Human Services, 2011a, 2011b). The Perinatal Care Core Measure Set for breastfeeding was established by The Joint Commission (TJC) in 2009 (TJC, 2009). Surgeon General, Regina M. Benjamin called for action to support breastfeeding in 2011 (United States Department of Health and Human Services, 2011a, 2011b). With all of these endorsements and evidence, the supplementation of breastfeeding newborns in New York State is approximately 75% at hospital discharge (CDC, 2009). Participation in the BQIH Learning Collaborative exposed deficiencies in the care delivery model related to supporting exclusive breastfeeding in our hospital. Maternity practices in hospitals influence breastfeeding initiation, duration, and exclusivity (Brown et al., 2011; Declercq et al., 2009; Shealy et al., 2005) The key elements: leadership support, education of staff, feedback from staff throughout each P-D-S-A cycle, implementation of recommended system changes based on staff involvement and feedback, and reporting of the BQIH Learning Collaborative indicators through the hospital's Quality Program identified in this project can be replicated to help other institutions throughout NYS to support exclusive breastfeeding.


Suggested Clinical Implications


* Process change requires a systematic approach


* Active leadership involvement is essential to implementing complex organizational change


* Direct care provider input and feedback are necessary for success


* Collaborative sharing maintains momentum to foster change


* On-line education can be helpful in insuring all members of the team have the same knowledge base


* Quality improvement drives process change


* Implementing research interventions such as, The Ten Steps to Successful Breastfeeding, positively influences exclusive breastfeeding rates



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