Massachusetts Breastfeeding Coalition

How is Massachusetts Doing?

The MBC Nurse Manager Survey of Breastfeeding Practices

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).

Click here to view abstract in Maternal/Child Health.

TABLE 1. The Ten Steps to Successful Breastfeeding, World Health Organization & United Nations Children’s Fund
  1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
  2. Train all health care staff in skills necessary to implement this policy.
  3. Inform all pregnant women about the benefits and management of breastfeeding
  4. Help mothers initiate breastfeeding within a half-hour of birth.
  5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
  6. Give newborn infants no food or drink other than breast milk, unless medically indicated.
  7. Practice rooming-in—allow mothers and infants to remain together—24 hours a day.
  8. Encourage breastfeeding on demand.
  9. Give no artificial teats or pacifiers to breastfeeding infants.
  10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

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.

TABLE 2. Survey Indices
  • Step 1
    Hospital-wide breastfeeding policy that affects breastfeeding care plan(s) exists.
    Breastfeeding policy is made known to staff and patients.
  • Step 2
    All new postpartum staff members are required to attend breastfeeding orientation.
    Hospital offers 10 or more clock-hours per year of continuing breastfeeding education for staff.
    Hospital encourages staff to receive additional breastfeeding education outside of the hospital.
  • Step 3
    Hospital offers prenatal classes which emphasize and support breastfeeding.
    Hospital offers breastfeeding classes.
    Materials about breastfeeding are available for parents on the postpartum floor.
  • Step 4
    Post-delivery nursery stay is infrequent or brief in duration to encourage rooming-in.
    Breastfeeding is initiated within a half-hour of birth.
  • Step 5
    Have sufficient staff available to support breastfeeding instruction.
    Teach mothers breastfeeding basics.
    Help mothers who are separated from their infants to initiate lactation.
  • Step 6
    Breastfeeding infants are not routinely supplemented with non-breast milk nutrition.
    Staff does not routinely give non-breast milk nutrition to breastfeeding mothers.
    Hospital does not promote or advertise non-breast milk supplementation.
  • Step 7
    Hospital staff encourages 24 hour rooming in.
    Hospital policy or typical practice permits rooming in except in extreme circumstances.
  • Step 8
    Breastfeeding mothers are taught how to feed their infants on demand.
    Staff facilitates feeding on demand.
    Patient visiting hours are enforced to facilitate breastfeeding on demand.
  • Step 9
    Pacifiers are not routinely used in breastfeeding infants.
    Staff assists breastfeeding mothers in avoiding pacifier use.
  • Step 10
    Breastfeeding mothers are routinely referred to community breastfeeding support services at discharge.
    Hospital provides post-discharge breastfeeding support/follow-up for breastfeeding mothers.


TABLE 3. Overall Mean Scores, Rankings, and Percentage of Low, Partial, Moderately High, and High Implementing Hospitals by Step in MA
    STEP        Overall    Score    Overall    Category
Hospital Policy
59% Partial
Staff Training 76% Mod. High
Prenatal Education
89% Mod. High
Early Initiation
77% Mod. High
Postpartum Instruction
79% Mod. High
74% Partial
80% Mod. High
On-demand Feeding
79% Mod. High
Pacifier Use
65% Partial
STEP 10:
Community Support
79% Mod. High