Is any progress good progress?

I’m always intrigued when Google Alerts sends me something other than Mother Breastfeeds Dog To ‘Feel Complete’ or So and So Apologizes to Breastfeeding Mother for Telling Her to Cover Up or Male Stranger Shames Breastfeeding Mother on Facebook. So when I received Jefferson Healthcare receives gold standard award for Breastfeeding Friendly Hospitals, I got curious and wanted to know more about the Breastfeeding Friendly Washington Hospitals initiative.

As you know, Cindy Turner-Maffei, MA, ALC, IBCLC is my go-to for everything parenting-related. She’s talked me through puking babies, bloody nipples and peanut-buttery baby poo.

She also served as National Coordinator of Baby-Friendly USA, Inc. (BFUSA), implementing the UNICEF Baby-Friendly Hospital Initiative in the United States for 14 years, so it made sense to go to her with questions about a similar initiative. (Cindy did remind me that she is no longer affiliated with BFUSA and does not speak on their behalf.)

It turns out, Cindy isn’t specifically familiar with the Breastfeeding Friendly Washington Hospitals Initiative. She does however have thoughts about similar state breastfeeding friendly hospital initiatives.

First, here’s a bit of background on some of the programs. Most of the initiatives that I’m aware of– Breastfeeding Friendly Washington Hospitals, Colorado Can Do 5, The Gift, North Carolina Maternity Center Breastfeeding Friendly Designation Program, The D.C. Breastfeeding Friendly Hospital Initiative, and the Texas Ten Steps Initiative— were developed to recognize maternity centers that have implemented some of the BFHI 10 Steps to promote, protect and support breastfeeding.

In North Carolina, for example, “A star is awarded for every two steps achieved in the Ten Steps to Successful Breastfeeding.” Breastfeeding Friendly Washington Hospitals uses a bronze, silver and gold recognition system.

Some of the initiatives are marketed as starting points for BFHI, but I wondered why states wouldn’t begin their journey with BFHI considering it offers a guided step by step process.

Cindy’s thoughts: “The U.S. was slow to embrace the BFHI. In the 1990s when many countries in the world were charging forward to implement the initiative, the government took nearly four years to study the feasibility of a U.S. BFHI. Many in the U.S. thought that implementing the BFHI here was impossible. Others were ready to charge ahead.”

She says people didn’t understand how the initiative would work in US settings without many experiences to share and without a central authority to provide oversight and direction.

“Perhaps those who were eager to begin thought that breaking the initiative down into smaller steps would be helpful,” Cindy wonders.

In fact, the North Carolina initiative specifically encourages maternity centers across the state “to promote and support breastfeeding one step at a time” on their website.

Cindy’s first concern: “Smaller” baby-friendly-esque programs add another layer to the interpretation of the 10 steps.

“It confuses things,” Cindy explains. “And it potentially changes what people think they have to do.”

For example, one maternity care giver she met recently was mistakenly under the impression that switching nipple cream brands was part of BFHI.

Cindy’s next concern: It’s her understanding that state initiatives could be relying on self-reported practice, unlike BFHI.

The WHO/UNICEF BFHI is based on solid evidence (see the UK Baby-Friendly Initiative’s recent review of the evidence behind the program), and periodically updated, standardized guidelines and evaluation criteria. The facility evaluation process is conducted with standardized assessment tools, by specifically trained, objective, unbiased assessors. In the U.S., assessment findings are reviewed as well by a blinded external review committee.

And Cindy’s biggest concern: If state initiatives are successful in their mission, why don’t their mPINC scores reflect that?

mPINC is the acronym for the CDC’s Maternity Practices in Infant Nutrition and Care, which is a survey of practices addressing the Ten Steps to Successful Breastfeeding. mPINC is administered biannually by the CDC to all birthing facilities nationwide since 2007.

The charts below summarize what Cindy found from examining Texas and California data on the CDC report cards for 2007-2014. She chose Texas because the Texas Ten Steps Initiative is the oldest (launched in 1999) of the state breastfeeding friendly initiatives. She used California as a comparison state because it is also large and has a similar immigration and ethnic blend. There was no report card published this year, however there will be one next year as a biannual report. Instead, Cindy included 2015 breastfeeding rate information from the National Immunization Survey.

CDC reports the following data in the Breastfeeding Report Card (published annually from 2007 through 2014, and moving to bi-annual schedule in 2015.)

mPINC data has been collected biannually since 2007 – breastfeeding rates and Baby-Friendly birth rates annually, thus data from mPINC listed only once below for every 2 year span.

Texas vs. US

Year mPINC scoreTX avg    USA avg % births in a BFHI facilityTX avg         USA avg BF Initiation ratesTX avg    USA avg
2007 0% 1.79% 75.4% 73.8%
2008 58 63 0 1.93 77.9 74.2
2009 0.93 2.87 78.2 73.9
2010 62 65 3.29 3.78 75.8 75.0
2011 3.22 4.53 75.2 74.6
2012 66 70 4.66 6.22 80.3 76.9
2013 4.77 7.15 77.2 76.5
2014 73 75 3.35 7.79 78.4 79.2
2015 14.31^ 83.3* 80.0*

By comparison, California, a state with no known similar program, has demonstrated strong and growing breastfeeding initiation rates that appear to be correlated with increases in both births in a Baby-Friendly hospital, and state average mPINC scores.

California vs. US

Year mPINC scoreCA avg    USA avg % births in a BFHI facilityCA avg         USA avg BF Initiation ratesCA avg    USA avg
2007 3.28% 1.79% 83.8% 73.8%
2008 69 63 4.55 1.93 85.1 74.2
2009 8.4 2.87 84.7 73.9
2010 73 65 10.85 3.78 86.6 75.0
2011 14.59 4.53 86.6 74.6
2012 79 70 21.39 6.22 87.6 76.9
2013 24.82 7.15 91.6 76.5
2014 83 75 26.97 7.79 92.8 79.2
2015 14.31^ 88.3* 80.0*

* NIS data for births in 2012: Overall and State

^As reported by Baby-Friendly USA on 9/18/15

Cindy found that Texas mPINC scores are lower than the national average, as well as percent of births in a BFHI designated facility.

“Meanwhile TX breastfeeding rates have been higher than the national average throughout this time span,” Cindy explains.

Hispanic women have the highest breastfeeding initiation rate. Cindy wonders how this affects the state average for both California and Texas.

Scores are higher in California than both the Texas and the national rates for mPINC and births in a Baby-Friendly designated facility. California has certainly been in the vanguard of implementing the BFHI as well as other breastfeeding-focused initiatives, but there has not been a statewide 10-step-like program promoted in that state.

Cindy reminds me that she thinks state initiatives begin with the best of intentions, and may provide motivation for birth facilities to begin to change maternity care practices. But is any progress good progress? She’s not convinced, and calls for research to examine the impact of these state programs on breastfeeding outcomes.

Cindy cautions that self-reported practice is not the same as that which has been verified by an outside evaluation, the type of assessment offered by Baby-Friendly USA.

She points out: “Practice in health care settings does not always mirror written policy. What administrators and staff believe is happening does not always mirror the experiences reported by mothers. Observing practice, as well as interviewing individual families and staff members, provides far greater depth of information than reviewing written policies and facility-reported data about practice alone. That is the strength of an outside, on-site assessment process such as that offered by the BFHI.”
This month’s CDC Vital Signs report presents information on hospital support for breastfeeding. Find out how ‘Hospital Actions Affect Breastfeeding’ here.

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.