Brief Summary of Findings of the New Hampshire Ten Steps
to Successful Breastfeeding Birthing Hospital Needs Assessment

Joyce Kelly, RN, MPH       Bonny Whalen, MD, IBCLC       Allison Holmes, MD, MPH, FABM

PURPOSE: To determine current level of implementation of ten evidence-based maternity-care practices supportive of breastfeeding (Ten Steps to Successful Breastfeeding) in New Hampshire's birthing hospitals. Findings are directing funding efforts to help interested hospitals improve their level of Ten Step breastfeeding support and achieve Baby-Friendly designation when desired.

PROCESS: Over a period of 5 months (September 2010 to January 2011), we performed a survey of NH's 21 birthing hospitals' evidence-based maternity-care practices supportive of breastfeeding. Survey questions were based upon the Baby Friendly USA's self-appraisal tool. Each birthing unit's nurse manager gave permission to conduct the survey. All 21 hospitals completed the survey. Data were collected in person (13), via phone interview (1), on-line (5) or by paper questionnaire (2).

OVERVIEW OF FINDINGS: Three NH hospitals are currently Baby Friendly USA certified (Alice Peck Day, Concord, St. Joseph's). At the time of the survey, four other hospitals had applied for intent to become Baby-Friendly certified or were in the process of doing so (Dartmouth-Hitchcock, Monadnock, Cheshire, Wentworth-Douglas). Others indicated they were actively working to improve their level of Ten Step support and/or were taking steps to become Baby-Friendly certified.

Step 1 - Breastfeeding policy: Hospitals should have a formal written policy that addresses the Ten Steps to Successful Breastfeeding, and is routinely communicated to all staff.

  • Step fully met by 15 of 21 hospitals (71%).
  • All hospitals had a breastfeeding policy, but not all policies met each of the ten model steps.
  • 6 hospitals (30%) did not communicate the policy to all health care staff, including physicians.

Step 2 - Staff education: Hospitals should train all staff in skills necessary to implement breastfeeding policy. At time of survey, nursing staff needed 18 hr of training in management and care of the breastfeeding dyad with 3 hr of supervised clinical experience (BFHI now requires 20 hr training with 5 hr supervised clinical experience); physicians and other advanced level providers need 3 hr of training in benefits and management of breastfeeding.

  • Step fully met by 2 of 21 hospitals (9.5%).
  • Only 12 hospitals (57%) had 80% or more of nurses trained in BCEP or equivalent.
  • Physician training remains one of the most difficult obstacles. Only 2 hospitals had at least 80% of their physicians trained.

Step 3 - Inform pregnant women about breastfeeding: Hospitals should ensure all pregnant women are informed of the benefits and management of breastfeeding, regardless of initial feeding preference.

  • Step fully met by 12 of 21 hospitals (57%).
  • 9 hospitals (43%) indicated that pregnant women are not routinely informed of the benefits and management of breastfeeding.
  • The majority of breastfeeding prenatal education is provided by an OB provider (76%) or nurse (43%).
  • 16 of 21 hospitals (76%) reported less than half of moms attend prenatal breastfeeding education classes despite their availability.

Step 4 - Prompt skin-to-skin and early breastfeeding: Hospitals should ensure all babies are placed skin-to-skin with their mothers within 30 minutes of vaginal delivery and within 30 minutes of when a mother is able to respond to her baby after cesarean delivery. Babies should be allowed to stay skin-to-skin for at least the first hour, and mothers should receive help with breastfeeding within this first hour.

  • Step fully met by all 21 hospitals.
  • Hospitals still reported barriers to skin-to-skin contact and early initiation of breastfeeding that included presence of family/visitors immediately after birth, maternal procedures, post-cesarean section care, and reluctance of the mother.

Step 5 - Show mothers how to breastfeed and maintain lactation: Hospitals should provide direct assessment of and instruction for breastfeeding within 6 hr of delivery (within 3 hr optimally) and continue to provide assessment/instruction thereafter. All mothers should be shown how to hand express their milk. Mothers who are separated from their infants should be shown how to electronically express their breast milk.

  • Step fully met by 20 of 21 hospitals (95%).
  • 60% of hospitals have professional lactation support 5 days/week; only 30% have coverage 7 days/week.

Step 6 - No supplements unless medically indicated: Hospitals should give breastfeeding newborns no food or drink other than breast milk - unless medically indicated. Hospitals should educate breastfeeding mothers about potential negative consequences of formula use in breastfed infants. Hospitals should refuse free or low cost formula and refrain from formula supplementation of breastfed infants unless a medical indication is present.

  • Step fully met by 4 of 21 hospitals (19%).
  • The majority (91%) reported that breastfeeding infants can receive formula without a medical indication. The most commonly reported reason for supplementation without a medical indication was maternal request.
  • 12 hospitals (57%) reported that mothers routinely receive education about the potential negative consequences of medically unnecessary supplementation, whereas 6 hospitals (29%) reported that mothers sometime receive this education, and 3 (14%) reported that mothers never receive this education.
  • 16 hospitals (76%) receive free formula or pay below market value for formula.
  • 5 hospitals (24%) provide diaper bags with formula samples or coupons at discharge.

Step 7 - Rooming-in: Hospitals should encourage/provide rooming-in 24 hr/day as the standard for mother-baby care for healthy, full-term infants, regardless of feeding choice (starting within 1 hr of birth, and with 1 hr / day permitted for procedures outside of the room). If mother requests that her baby be taken to the nursery, staff should explore request and educate mother about advantages of rooming-in. If mother still requests that her baby be cared for in the nursery, process and informed decision should be documented.

  • Step fully met by 17 of 21 hospitals (81%).
  • All hospitals had a rooming-in policy, but barriers to full implementation still present for some.
  • Primary reasons for separation and barriers to full implementation included maternal request and staff or visitor's idea that mother needs time to sleep.

Step 8 - Encourage feeding on cue: Hospitals should advise mothers to feed their babies when the infant demonstrates feeding cues, and without restriction on frequency or length of time. Hospitals should educate mothers on infant's ability to indicate feeding cues and self-regulate feedings, and to expect at least 8 feedings/24 hr.

  • Step fully met by all 21 hospitals.
  • All hospitals educated mothers on feeding on cue without restrictions.

Step 9 - No artificial nipples: Hospitals should educate mothers about how the use of bottles and artificial nipples may interfere with the development of optimal breastfeeding. Supplementation of infants (whether medically indicated or following informed decision of mother) should be given by a tube, syringe, spoon, or cup in preference to an artificial nipple or bottle.

  • Step fully met by 10 of 21 hospitals (48%).
  • 15 hospitals (71%) have finger feeding or Supplemental Nursing System (SNS) as primary method of supplementation, but 18 hospitals (86%) also allowed use of a bottle with standard nipple.
  • Pacifiers are not routinely given to breastfed infants in 19 hospitals (90%), but they are still given at the mother's request at almost all hospitals (90%).
  • 17 hospitals (80%) provide informed education regarding potential negative consequences of pacifier or artificial nipple use.

Step 10 - Post-discharge breastfeeding support: Hospitals should encourage and assist mothers with discharge breastfeeding support, which can include mothers' groups, lactation clinic visits, and phone calls.

  • Step fully met by 20 hospitals (95%).
  • Many hospitals offer on-site breastfeeding support groups (62%) and outpatient lactation visits in Lactation Clinic (76%).
  • 19 hospitals (90%) offer direct phone line to nurse on birthing unit and/or phone call follow-up.