In 2003, the Massachusetts Breastfeeding Coalition conducted a survey of all the maternity nurse managers in Massachusetts. We wanted to see how well hospitals in the state complied with evidence-based best practices around breastfeeding. We used the World Health Organization’s Baby Friendly Ten Steps, as these steps are all associated with better sustained breastfeeding rates. (see table 1).
We chose to interview nurse managers, rather than other staff members, because the nurse managers are considered the leaders of their units, and any decisions to implement practices must generally go through them. Their perception of the practices in their units would be important. Prior to the study, we had anecdotal evidence that nurse managers sometimes did not see themselves as having an important role in the development of policies conducive to breastfeeding, often referring all questions and comments to the lactation professionals in their departments.
We developed a survey instrument to elucidate compliance, or perceived compliance, to the Ten Steps. All respondents were assured of anonymity, and only the interviewer is aware of their identities. Each hospital was rated by the compliance with implementing the steps. The hospitals were described as either non-implementers, partial implementers, moderately high implementers, and high implementers.
In Massachusetts, no nurse manager described her hospital as a “non-implementer” for any of the steps.
We found that several key factors separated high/moderately high implementers from partial implementers. Control of pacifier use and supplementation, number of staff available for breastfeeding teaching, and referral to community breastfeeding supports were important distinctions between the high/moderately high implementers and partial implementers. Sixty percent of Massachusetts hospitals are high or medium-high implementers of the Ten Steps and 40% are partial implementers.
Hospitals that did not accept free formula had statistically significantly higher levels of Ten Steps implementation overall. There were strong associates between implementation and certain hospital characteristics, particularly formula-acceptance status and accessibility of formula without a physician order.
Our data enabled us to identify four major opportunities for quality improvement in Massachusetts hospitals. These areas include hospital breastfeeding policy, formula availability, and pacifier usage. Together they comprise the majority of problems seen among hospitals in our survey, making them current targets for community-based and statewide interventions.
|STEP||Overall Score||Overall Category|
|Staff Training||76%||Mod. High|