Achieving Baby-Friendly Hospital Designation: A Fiscal Plan

Introduction and Problem Statement

The purpose of this project is to work toward Baby-Friendly Hospital Designation (BFHD) for a hospital in the Brownsville section of Brooklyn, New York. There are many reasons for pursuing this designation: it is both prestigious and likely to improve the hospital's practices as they relate to evidence-based maternity care regarding breastfeeding and maternal and infant health. Baby-Friendly Hospital Designation will ultimately save lives, as the policies and practices associated with it will improve breastfeeding rates among new mothers and improve infant and maternal health in both the short and long term.

The hospital in question is an academic teaching institution serving primarily minority, low-income, and immigrant families in the Brownsville/East New York section of Brooklyn. In Brownsville, 11 infants died out of every 1,000 live births from 2007 to 2009 — twice the city rate — closely followed by the East New York and Bedford-Stuyvesant sections of Brooklyn, according to the New York City Department of Health and Mental Hygiene (NYCDOHMH, 2010). Breastfeeding is not sufficiently supported in this population due to practice protocol, institutional standards, and ethnic and other social factors.

Exclusive breastfeeding among women with infants aged 0–3 and 0–6 months is clearly associated with a reduction in infant mortality rates and health complications caused by poor nutrition and decreased immune system function ("Breastfeeding-related maternity practices…," 2008). Breastfeeding promotes infant health even when maternal health is compromised — including in cases of maternal cigarette smoking (Dorea, 2007) — and is also a mitigating factor in reducing later childhood obesity, a growing problem in the U.S. and elsewhere that creates a strong predisposition for obesity in adulthood (Bainbridge, 2009, p. 393). Breastfeeding also clearly reduces rates of several minor and major infectious diseases in infants and children, diseases that are costly to treat and can result in infant mortality. It is therefore extremely important to institute functional, evidence-based changes to increase breastfeeding rates in this community, and obtaining the Baby-Friendly designation can make a significant difference in maternal breastfeeding outcomes and, consequently, in infant and maternal health.

The current maternity care practices at this hospital must be improved. Although poor breastfeeding practice and support is a national trend ("Breastfeeding support falling short at U.S.…," 2008), the ethnic composition and socioeconomic status of those served at this hospital create an even more serious need for the implementation of Baby-Friendly Hospital Designation and its associated requirements (see the Ten Steps to Successful Breastfeeding, Appendix 1). Breastfeeding rates — and exclusive breastfeeding rates in particular — are extremely low at this hospital, and some of the reasons are evident in the policies and practices surrounding maternity care. These policy and practice issues can be addressed to improve breastfeeding rates and to introduce both the practice and the importance of exclusive breastfeeding to the patient population. There is every reason to hope that doing so will mitigate ethnic and other social barriers to breastfeeding, as has occurred at other similar hospitals that have instituted change and pursued Baby-Friendly Hospital Designation.

In the delivery room, babies are not routinely placed on the mother's abdomen as stated in the hospital's breastfeeding policy, and rooming-in is not routinely encouraged or practiced. A separate newborn nursery on the maternity unit is well used, with nurses rather than mothers providing most newborn care. Routine newborn screening tests are performed in the nursery, whereas they could be conducted at the mother's bedside. The literature consistently shows that any separation of infant from mother reduces the chance of early physical bonding and diminishes the infant's instinct to suckle.

Breastfeeding education is provided in prenatal clinics, but many patients do not receive regular prenatal care. It is therefore critical to initiate breastfeeding education at the first hospital encounter and to continue it consistently throughout the hospitalization, with appropriate referrals upon discharge to support exclusive breastfeeding. Low rates of breastfeeding initiation are partly attributable to cultural and ethnic factors, maternal health concerns, and other issues — but improvement is an achievable goal with both short- and long-term cost-saving and health benefits. There is currently no Certified Lactation Consultant position at the hospital, which presents a significant challenge for early breastfeeding initiation, patient teaching, and post-discharge follow-up. As part of the Baby-Friendly Hospital Designation rollout, a Certified Lactation Consultant will be hired.

Several initiatives are already underway to improve the situation. A new breastfeeding policy has been written and implemented based on updated World Health Organization (WHO) and United Nations Children's Fund (UNICEF) Joint Commission guidelines (MacEnroe, 2010). All nurses from Labor and Delivery, Maternity, and the NICU are encouraged to attend a Department of Health-sponsored Certified Lactation Counseling Course — a week-long program resulting in formal certification. To date, 80% of all registered nurses in the department have completed this course. It provides evidence-based knowledge about the benefits of breastfeeding as well as practical teaching skills. Breastfeeding classes are currently offered three times per week on the maternal-baby unit by certified nurses for mothers admitted after delivery.

Literature Review

The hospital has also applied for a Breastfeeding Initiative Grant. The New York City Department of Health and Mental Hygiene received a two-year grant from the U.S. Department of Health and Human Services (HHS), Centers for Disease Control and Prevention (CDC), funded through the American Recovery and Reinvestment Act of 2009 as part of the HHS "Communities Putting Prevention to Work Initiative." This initiative uses policy, systems, and environmental changes at the community level to create healthy environments and reduce obesity. Breastfeeding has been identified as an important component of childhood and adult obesity prevention, and the grant will help build on prior work to increase breastfeeding duration and exclusive breastfeeding rates (Grummer-Strawn & Shealy, 2009; American Academy of Pediatrics, 2005).

The New York City Department of Health and Mental Hygiene's Bureau of Maternal, Infant and Reproductive Health (BMIRH) sought up to four New York City hospitals working to improve their breastfeeding rates among healthy infants with no medical contraindications to receive a two-year grant (see Appendix 2). BMIRH will partner with recipient hospitals to institute policies, procedures, data collection, and other activities designed to improve breastfeeding exclusivity, duration, and support. This grant, along with other concurrent activities, will be a great help in first improving maternity care and ultimately achieving Baby-Friendly designation. The hospital has secured one of the four available grants.

Currently, the hospital has very low breastfeeding rates and high rates of treatment for diseases and complications that are worsened by the absence of breastfeeding. The short-term economic implications include the demonstrated increase in exclusive breastfeeding rates seen at other institutions that have achieved Baby-Friendly Hospital Designation (Merewood & Phillip, 2001; Naylor, 2010). With this designation, the hospital stands to avert a significant share of the short- and long-term costs of treating infants and mothers who experience negative health outcomes due to lack of breastfeeding.

Savings associated with Baby-Friendly Hospital Designation may be difficult to track in full, given the profound and far-reaching impact breastfeeding has on the health and wellness of both mother and child over a lifetime. Nevertheless, the hospital should begin to see changes in infant and maternal health outcomes within the first year of the five-year designation process, including a reduced rate of infant infectious disease. These savings will multiply over time to support a healthier community and a broader shift in community understanding of breastfeeding as the optimal feeding choice for infants. One early and measurable change associated with increased breastfeeding is a reduction in the number of infant patients presenting to the emergency room for non-life-threatening and life-threatening diseases more commonly seen in non-breastfed infants. According to the American Academy of Pediatrics, diseases reduced by breastfeeding include "bacterial meningitis, bacteremia, diarrhea, respiratory tract infection, necrotizing enterocolitis, otitis media, urinary tract infection, and late-onset sepsis in preterm infants. In addition, postneonatal infant mortality rates in the United States are reduced by 21% in breastfed infants" (AAP, 2005, p. 496).

Evidence-based practice demonstrates a universal need for better maternal and newborn care, particularly with regard to breastfeeding support and encouragement. This is evidenced by extensive research documenting both the optimal goals of higher exclusive breastfeeding rates among infants aged 0–6 months and the gap between those goals and current practices (AAP, 2010; Scanlon et al., 2007; Naylor, 2010; Grummer-Strawn & Shealy, 2009). These researchers and experts base their observations on well-documented needs: the current state of breastfeeding support in maternity settings and the clinical, short- and long-term health outcomes associated with breastfeeding and its absence. The literature is clear that the best overall scenario for maternal and infant health is exclusive breastfeeding until six months of age, with supplements or age-appropriate foods added thereafter. This approach is associated with a reduction in the incidence and severity of several infectious diseases and reduces infant mortality rates by more than 21% (AAP, 2005, p. 596).

The emphasis on breastfeeding is further supported by numerous policy statements, research bodies, and expert organizations. Exclusive breastfeeding is associated with better health outcomes for infants and mothers regarding "diabetes (both type 1 and type 2), lymphoma, leukemia, and Hodgkin disease, overweight and obesity, hypercholesterolemia, and asthma in older children and adults who were breastfed, compared with individuals who were not breastfed" (AAP, 2005, pp. 496–497). Additionally, research indicates that breastfed infants demonstrate more advanced neurodevelopment (AAP, 2005, p. 497), have better health outcomes even when maternal health is compromised, and that breastfeeding also supports maternal physical and mental health and well-being (AAP, 2005, p. 497).