Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, HEALTH_CARE_PROVIDER_PRACTICE, ,

Intervention Description: The aims of this study were to (1) assess changes to maternity care policies in response to COVID-19, and (2) compare hospital-level breastfeeding, skin-to-skin, and rooming-in rates, at cohort hospitals, before and during the pandemic, overall and stratified by race.

Intervention Results: Twenty-six hospitals responded to the May and September 2020 surveys. Hospitals used different sources to create maternity care policies, and policies differed between institutions. Trends in rates of any and exclusive breastfeeding in the hospital cohort plateaued during the pandemic, in comparison to previous gains, and rates of skin-to-skin and hospital rooming-in decreased. No differences were evident between races.

Conclusion: Policies (Aim 1) and practices in the quality improvement cohort hospitals were inconsistent during the COVID-19 pandemic, and changes measured to practices were detrimental (Aim 2). Ongoing monitoring is recommended.

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative, PATIENT_CONSUMER, Quality Improvement/Practice-Wide Intervention, Expert Support (Provider)

Intervention Description: The aims of Mississippi Communities and Hospitals Advancing Maternity Practices (CHAMPS) were to (1) increase breastfeeding initiation and exclusivity and (2) decrease racial disparities in breastfeeding by increasing the number of Baby-Friendly hospitals in the state from 2014 to 2020.

Intervention Results: Between 2014 and 2020, the number of Baby-Friendly hospitals in Mississippi rose from 0 to 22. Breastfeeding initiation in the hospitals increased from 56% to 66% (P < .05), and the disparity between Black and White dyads decreased by 17 percentage points, an average of 0.176 percentage points each month (95% confidence interval: −0.060 to −0.292). Exclusivity increased from 26% to 37% (P < .05). Skin-to-skin and rooming-in rates increased significantly for all dyads: 31% to 91% (P < .01) for skin-to-skin after vaginal birth, 20% to 86% (P < .01) for skin-to-skin after cesarean delivery, and 19% to 86% (P < .01) for rooming-in.

Conclusion: Over the course of the CHAMPS program, there were significant increases in breastfeeding initiation and exclusivity, and decreases in racial inequities in breastfeeding initiation.

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Baby Friendly Hospital Initiative, Quality Improvement/Practice-Wide Intervention, Hospital Policies, Provider Training/Education

Intervention Description: To conduct a national quality improvement initiative between 2011 and 2015. The initiative was entitled Best Fed Beginnings and enrolled 90 hospitals in a nationwide initiative to increase breastfeeding and achieve Baby-Friendly designation.

Intervention Results: Overall breastfeeding increased from 79% to 83% (t = 1.93; P = .057), and exclusive breastfeeding increased from 39% to 61% (t = 9.72; P < .001).

Conclusion: A nationwide initiative of maternity care hospitals accomplished rapid transformative changes to achieve Baby-Friendly designation. These changes were accompanied by a significant increase in exclusive breastfeeding.

Study Design: QE: pretest-posttest

Setting: 90 hospitals from 3 geographic regions

Population of Focus: Hospitals with low breastfeeding rates, readiness for change, establishment of a BabyFriendly/breastfeeding steering committee, data about sociodemographic characteristics of population served, geographic location based on regions with low breastfeeding rates and BFHI accreditation, commitment of senior leadership, and experience with quality improvement methods

Data Source: Medical record review

Sample Size: Intervention (N=89) N=hospitals

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Quality Improvement/Practice-Wide Intervention, Baby Friendly Hospital Initiative,

Intervention Description: The Best Fed Beginnings (BFB) initiative was specifically aimed to enable 90 hospitals to earn Baby-Friendly USA assessment scheduled by the end of the collaborative project. Given the size of this initiative, BFB was conducted as 3 simultaneous Breakthrough Series collaborative projects comprising hospitals from 3 geographic regions. Hospitals assembled multidisciplinary teams that included parent partners and community representatives. Three in-person learning sessions were interspersed with remote learning and tests of change, and a Web-based platform housed resources and data for widespread sharing.

Intervention Results: By April 2016, a total of 72 (80%) of the 90 hospitals received the Baby-Friendly designation, nearly doubling the number of designated hospitals in the United States. Participation in the Best Fed Beginnings initiative had significantly high correlation with designation compared with hospital applicants not in the program (Pearson’s r [235]: 0.80; P < .01). Overall breastfeeding increased from 79% to 83% (t = 1.93; P = .057), and exclusive breastfeeding increased from 39% to 61% (t = 9.72; P < .001).

Conclusion: A nationwide initiative of maternity care hospitals accomplished rapid transformative changes to achieve Baby-Friendly designation. These changes were accompanied by a significant increase in exclusive breastfeeding.

Study Design: Evaluation data

Setting: Hospitals nationwide

Population of Focus: Hospitals across the country seeking to achieve Baby-Friendly designation

Sample Size: 90 Baby-Friendly Hospitals

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational material, HEALTH_CARE_PROVIDER_PRACTICE, Quality Improvement/Practice-Wide Intervention, Hospital Policies, Provider Training/Education,

Intervention Description: The purpose of this system-wide quality improvement project was to create a breastfeeding-friendly pediatric practice. This breastfeeding support initiative was implemented at a multisite rural Illinois pediatric practice. The policy included: (a) breastfeeding promotion recommendations; (b) provider, nurse, and staff roles; (c) patient education and resources; and (d) breastfeeding-friendly atmosphere guidelines. An evidence-based breastfeeding policy was developed, staff education sessions were conducted, private lactation rooms were created, and breastfeeding photographs/posters were displayed throughout the offices. Lactation support services were publicized throughout the offices. Lactation support services were publicized via signs and social media postings.

Intervention Results: Overall breastfeeding rates were higher at each time point after implementation. Statistically significant increases occurred at the newborn and 1-month visits, with a modest improvement at 2 and 4 months.

Conclusion: This project demonstrated an improvement in breastfeeding duration rates. It is anticipated that this practice-wide standard of care change will promote breastfeeding throughout the first 12 months of life.

Study Design: Pre-post intervention

Setting: Multisite rural IL pediatric practice

Population of Focus: Mothers with breastfeeding infants from newborn to 4 months seen for well-child visits at a pediatric practice

Sample Size: 71 infants preintervention and 18 infants postintervention

Age Range: Newborn to infants 4 months old

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, HEALTH_CARE_PROVIDER_PRACTICE, ,

Intervention Description: Our specific aims were two-fold: 1) Accurately measure breastfeeding indicators and 2) Implement AAP Breastfeeding-Friendly Pediatric Office Practice Recommendations.

Intervention Results: Since initiation of the data analytic tool, breastfeeding data has been analyzed from over 30,000 visits (86% Medicaid-insured, 82% Black race). Currently, 80% of providers use default templates that allow standardized data capture. At first newborn visit, 74% of infants were breastfed. At six months, 36% of infants were breastfed; 23% exclusively. Standardized documentation of infant feeding status improved and has remained consistent. Breastfeeding duration did not significantly improve despite practice interventions.

Conclusion: Pediatric primary care measurement tools are feasible and critical to understand breastfeeding continuation. Increased resources and interventions to support breastfeeding in Primary Care are necessary to improve outcomes.

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Educational Material

Intervention Description: To equitably increase exclusive breastfeeding at hospital discharge among obstetrician/gynecologist resident service clients by 20% over 8 weeks. Design

Intervention Results: Rates of exclusive breastfeeding at hospital discharge were 7% at baseline and 13% after implementation. Rates of exclusive breastfeeding among Black clients were 0% at baseline and 16% after implementation. Clients demonstrated Baby-Friendly knowledge (teach-back average, 89%) but continued to supplement with formula, most often related to supply concerns (65%).

Conclusion: Intentionally equitable implementation of the Baby-Friendly steps may ameliorate racial disparities in breastfeeding during the early postpartum period. Preparing families to exclusively breastfeed should begin prenatally.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Home Visits, PROVIDER/PRACTICE, Quality Improvement/Practice-Wide Intervention

Intervention Description: To measure progress towards the SMART aim, the HV CoIIN developed a common group of measures that LIAs report and analyze monthly. HV CoIIN measures were selected to capture key steps in the process of breastfeeding.

Intervention Results: The HV CoIIN’s theory of change includes a comprehensive approach to increasing the percentage of mothers that exclusively breastfeed their infants until they are three and six months of age by redesigning the ways we engage mothers, provide breastfeeding support in home visits, and ensure seamless linkages for mothers to access and engage in peer and community breastfeeding supports. Within the first eleven months, the HV CoIIN is generating promising movement toward breakthrough change across indicators, On average, 74% of all home visitors within the breastfeeding collaborative across 11-months, are being trained in lactation and infant feeding, with a trend in the data towards meeting our overall Process AIM. Over the last four months, the average has increased to more than 89%. On average, 69% of mothers with an identified need for breastfeeding support are receiving professional or peer breastfeeding support across the collaborative. Efforts in Action period three will aim to strengthen community and peer supports for families. The average percent of women exclusively breastfeeding is 16%, up 13 percentage points from the baseline of 3% of women.

Conclusion: The HV CoIIN’s theory of change includes a comprehensive approach for the development and implementation of reliable and effective systems for surveillance, screening, referral, follow-up, and intervention, with the goal of supporting all children’s development and getting vulnerable children access to appropriate and timely supports.

Study Design: Quality improvement time series design

Setting: Maternal, Infant, and Early Childhood Home Visiting Programs within FL, MI, OH, PA, RI, VA, WI

Population of Focus: Prenatal to age 3 children and families

Sample Size: • Phase 1 – 11 local teams (n≈1074) • Phase II – 9 sites (n≈873) N=families per month

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Hospital Policies, Baby Friendly Hospital Initiative, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: Using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, this study assessed CHAMPS, which used a Quality Improvement intervention at hospitals, and engaged intensively with local community partners.

Intervention Results: Average hospital breastfeeding initiation rates rose from 56% to 66% (p < 0.05), the proportion of hospitals designated Baby-Friendly or attaining the final stages thereof rose from 15% to 90%, and 80% of Mississippi Special Supplemental Programme for Women, Infants, and Children districts engaged with CHAMPS. CHAMPS also maintains a funded presence in Mississippi, and all designated hospitals have maintained Baby-Friendly status. These findings show that a breastfeeding-focused public health initiative using broad-based strategic programming involving multiple stakeholders and a range of evaluation criteria can be successful.

Conclusion: More breastfeeding promotion and support programmes should assess their wider impact using evidence-based implementation frameworks.

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Peer Counselor, HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER

Intervention Description: A breastfeeding-friendly physician’s office that applies the 13 recommendations of the Academy of Breastfeeding Medicine can help increase the exclusivity and duration of breastfeeding. Having already published the results up to five months of age of this intervention in our pediatric practice, we now report on the follow up to 36 months.

Intervention Results: The rates of any breastfeeding at discharge and at 1, 3 and 5 months (n = 252) were 95.2, 95.8, 89.3 and 86.5%, respectively. At 8, 12, 18, 24 and 36 months of age, the rates of breastfeeding were 70.6% (163/231), 59% (135/229), 35% (78/224), 24.6% (55/224) and 7.2% (16/224), respectively.

Conclusion: The rates of any breastfeeding recorded in our pediatric practice up to age 36 months, are much higher than those reported elsewhere in high income countries and are likely to be associated with our baby-friendly and biological nurturing approach.

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, , HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We aimed to improve the prevalence of EIBF among teenage mothers to at least 90% through a quality improvement (QI) initiative.

Intervention Results: The prevalence of EIBF among adolescent mothers was 28.5% during the pre-intervention baseline phase. QI team meeting was held and the barriers to EIBF among the adolescent mothers were discussed and depicted in the form of a fish-bone analysis model. The prevalence of EIBF increased during each intervention cycle to 50%, 60%, 62.5%, 72.7%, 88%, and 100%. At the end of six months follow-up phase, the prevalence of EIBF sustained at around 100%.

Conclusion: This QI initiative has proven to be effective in improving the prevalence of EIBF with simple but effective measures. Adolescent women comprise of a vulnerable sub-population of high-risk mothers. Proper counseling and respectful maternity care will help them face the challenges of motherhood boldly.

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, HEALTH_CARE_PROVIDER_PRACTICE, Midwifery

Intervention Description: We explored breast feeding outcomes of women having a First Nations infant at three sites that introduced a culturally specific continuity of midwife care model.

Intervention Results: Most women (298, 87%) received the culturally specific model. Breast feeding initiation (96%, 95% CI 0.93 to 0.98) was high. At 3 months, 71% were giving ‘any’ (95% CI 0.65 to 0.78) and 48% were giving ‘only’ breast milk (95% CI 0.41 to 0.55). Intending to breast feed 6 months (Adj OR ‘any’: 2.69, 95% CI 1.29 to 5.60; ‘only’: 2.22, 95% CI 1.20 to 4.12), and not smoking in pregnancy (Adj OR ‘any’: 2.48, 95% CI 1.05 to 5.86; ‘only’: 4.05, 95% CI 1.54 to 10.69) were associated with higher odds. Lower education (Adj OR ‘any’: 0.36, 95% CI 0.13 to 0.98; ‘only’: 0.50, 95% CI 0.26 to 0.96) and government benefits as the main household income (Adj OR ‘any’: 0.26, 95% CI 0.11 to 0.58) with lower odds.

Conclusion: Breast feeding rates were high in the context of service-wide change. Our findings strengthen the evidence that culturally specific continuity models improve breast feeding outcomes for First Nations women and infants. We recommend implementing and upscaling First Nations specific midwifery continuity models within mainstream hospitals in Australia as a strategy to improve breast feeding.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Quality Improvement/Practice-Wide Intervention,

Intervention Description: In Tennessee, a statewide, multidisciplinary development team reviewed evidence from the "Ten Steps to Successful Breastfeeding" to create a consensus toolkit of process indicators. The Tennessee Initiative for Perinatal Quality Care (TIPQC) is a statewide perintatal quality collaborative seeking to improve health outcomes for mothers and infants through large-scale quality improvement (QI) initiatives. All teams met in monthly webinar huddles (online group discussions), semiannual regional learning sessions, and an annual statewide TIPQC collaborative meeting. Monthly webinar meetings for the participating hospitals were held online, hosted and led by TIPQC and state leaders.

Intervention Results: Thirteen hospitals accounting for 47% of live births in Tennessee submitted data on 31,183 mother–infant dyads from August 1, 2012, to December 31, 2013. Aggregate monthly mean PC-05 demonstrated “special cause” improvement increasing from 37.1% to 41.2%, an 11.1% relative increase. Five hospitals reported implementation of ≥5 of the Ten Steps and two hospitals reported ≥90% reliability on ≥5 of the Ten Steps using locally designed process audits.

Conclusion: Using large-scale improvement methodology, a successful statewide collaborative led to >10% relative increase in breastfeeding exclusivity at discharge in participating Tennessee hospitals. Further opportunities for improvement in implementing breastfeeding supportive practices were identified.

Study Design: Evaluation data

Setting: Hospitals in TN

Population of Focus: Hospitals located in the Mississippi River Delta or Appalachia in TN

Sample Size: 13 hospitals with data on 31,183 mother-infant dyads