Improving Hospital Breastfeeding Policies in New York State: Development of the Model Hospital Breastfeeding Policy

Abstract

The public health importance of breastfeeding, especially exclusive breastfeeding, is gaining increased recognition. Despite a strong evidence base that key hospital maternity practices (Ten Steps to Successful Breastfeeding) impact breastfeeding initiation and exclusivity in the hospital and breastfeeding duration post-discharge, they are not widely implemented. In 2009, written hospital breastfeeding policies were collected from all New York State (NYS) hospitals providing maternity care services (n=139). A systematic assessment of the policies found that, on average, approximately half (19/32) the components required under NYS hospital regulations were included. Inclusion of each of the Ten Steps varied from 14% to 98%. An evidence-based Model Hospital Breastfeeding Policy was developed that included required components (based on NYS hospital regulations and legislation) and recommendations from expert groups such as the Academy of Breastfeeding Medicine, Baby Friendly USA, Inc., and the United States Breastfeeding Committee. Improved hospital breastfeeding policies are a critical first step in improving hospital maternity care to better promote, support, and protect breastfeeding. Additional efforts throughout health care, the workplace, and the broader community will be required to make breastfeeding the norm.

Introduction

Breastfeeding, especially exclusive breastfeeding, is of public health importance because of the recognized health benefits afforded to mothers and infants and the economic benefits accrued to families, communities, and insurers. Human (breast) milk is a source of complete nutrition for a human infant at minimal cost. Infants who are breastfed have a reduced risk for sudden infant death syndrome, childhood cancers, infectious diseases (otitis, pneumonia, gastroenteritis), obesity and diabetes. Mothers who breastfeed have a reduced risk for breast cancer, anemia, and osteoporosis.

Recently, there has been an increase in attention to breastfeeding support, promotion, and protection, both within New York State (NYS) and throughout the United States. Nationally, several breastfeeding objectives were added to Healthy People 2020, to build upon the breastfeeding objectives already included in Healthy People 2010. Targets in Healthy People 2020 were increased for breastfeeding initiation, breastfeeding at 6 months, breastfeeding at 1 year, breastfeeding exclusively at 3 months, and breastfeeding exclusively at 6 months over those in Healthy People 2010.¹ Surgeon General Regina M. Benjamin, M.D., released The Surgeon General's Call to Action to Support Breastfeeding,² and former NYS Health Commissioner Richard F. Daines, M.D., issued a Call to Action to promote breastfeeding, urging healthcare providers to increase awareness, reduce barriers, and improve knowledge and skills in promoting and supporting exclusive breastfeeding. In August 2009, NY Public Health Law § 2505-a, Breastfeeding Mothers' Bill of Rights³ (BFMBR), was passed by the NYS Legislature and signed into law by former NYS Governor David A. Paterson, effective May 1, 2010.

A strong evidence base demonstrates the key role that hospital maternity practices play in affecting breastfeeding initiation and exclusivity in the hospital and breastfeeding duration beyond discharge. A strong, written hospital breastfeeding policy is an important first step to improving hospital breastfeeding practices. NYS hospital regulations require that all NYS hospitals that provide maternity services have a written hospital breastfeeding policy. This article describes the assessment of these written hospital breastfeeding policies and the development of the NYS Model Hospital Breastfeeding Policy.

Materials and Methods

Review of NYS hospitals' breastfeeding policies

In May 2009, a letter was sent on behalf of the directors of the Offices of Public Health and Health Systems Management (responsible for ensuring that hospitals follow state and federal regulations) of the NYS Department of Health (NYSDOH) to hospital leadership, including the Chief Executive Officer, the Director of Maternity Care Services, the Chief of Neonatology, and the Chief of Obstetrics, at all NYS hospitals that provided maternity care services (in May 2009, n=139). The letter requested that each hospital submit to the NYSDOH a copy of their current written breastfeeding policy and supporting documentation, such as any protocols or procedures having to do with breastfeeding. The letter reminded leadership that under New York Codes, Rules and Regulations (NYCRR), Title 10, 405.21—Perinatal Services,⁴ hospitals that provide maternity care services are required to have a written hospital breastfeeding policy. Follow-up e-mails and phone calls ensured that all hospitals that provided maternity care services submitted their breastfeeding policy and supporting documentation for review.

To systematically review each hospital's breastfeeding policy, a draft codebook was developed based on 32 required components from the NYCRR. A sample of the hospital breastfeeding policies was reviewed, independently, by two coders, to test for inter-rater reliability. Policy coding results were discussed, and rating differences were resolved. The draft codebook was revised accordingly and reviewed by senior staff from the Office of Public Health and Office of Health Systems Management to ensure coding was consistent with NYCRR measures of compliance. The final NYCRR-based codebook identified 32 components, each of which was coded with a “1” if present, and a “0” if not present or incomplete (noncompliant). Each hospital breastfeeding policy was reviewed, using the final codebook, for presence or absence of each of the 32 required components.

The evidence-based Ten Steps to Successful Breastfeeding (Ten Steps), as outlined by the World Health Organization and UNICEF,⁵ were matched to the corresponding NYCRR-required components (Table 1). For each of the Ten Steps, a hospital policy was determined to include that Step if all of the corresponding components were included in the hospital's breastfeeding policy.

Table 1.

New York State Hospitals Providing Maternity Services (n=139) Whose Hospital Breastfeeding Policy Includes Each of the Ten Steps Based on the Required Components Specified in New York Codes, Rules and Regulations

Ten Steps to Successful Breastfeedinga	NYS hospital breastfeeding policy required components (2009)b	Hospitals [n (%)]
1. Have a written breastfeeding policy that is routinely communicated to all healthcare staff.	• A written policy is present, and	19 (14)
	• There is description about the procedure for dissemination/communication of policy among staff.
2. Train all healthcare staff in skills necessary to implement this policy.	• At least one person at the hospital is designated to ensure implementation of breastfeeding policy.	82 (59)
3. Inform all pregnant women about the benefits and management of breastfeeding.	• Information about the advantages of breastfeeding is provided to women who are undecided.	27 (19)
	• The process of caring for breasts is discussed with each breastfeeding mother.
	• Common problems associated with breastfeeding are discussed with each breastfeeding mother.
	• Maternal dietary requirements for breastfeeding are discussed with each breastfeeding mother.
	• Diseases and medications that might affect breastfeeding are discussed with each breastfeeding mother.
4. Help mothers initiate breastfeeding within half an hour of birth.	• Unless contraindicated, the newborn is placed for breastfeeding immediately (within 30–60 minutes) following delivery.	127 (91)
5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.	• Breastfeeding mothers are to be encouraged to maintain lactation if separated from their infant.	103 (74)
6. Give newborn infants no food or drink other than breastmilk, unless medically indicated.	• Supplemental feedings are only provided for the medical condition of the newborn or mother.	125 (90)
7. Practice rooming-in—that is, allow mothers and infants to remain together—24 hours a day.	• The option for rooming-in is available to mothers, 24 hours a day (for at least 6 hours of every 8-hour shift), unless it is medically contraindicated or the hospital does not have sufficient facilities.	110 (79)
8. Encourage breastfeeding on demand.	• There is a provision for the newborn to be fed on demand (no restriction on frequency or length of newborns' breastfeeds).	136 (98)
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.	• The hospital must respect a mother's decision to have her baby not receive any pacifiers.	83 (60)c
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.	• Advice and information about breastfeeding is available following discharge. (Can be in the form of a contact or birth center phone number.)	101 (73)

^aJoint World Health Organization/UNICEF statement published by the World Health Organization.⁵

^bAll required components for the 2009 review were based on the requirements specified in the New York Codes, Rules and Regulations (NYCRR), Title 10, 405.21—Perinatal Services.⁴

^cHospital policies were reviewed for inclusion of language restricting the use of pacifiers, even though this is not required under the NYCRR, Title 10, 405.21—Perinatal Services.⁴

NYS, New York State.

NYS regulation and legislation

The BFMBR codified and strengthened the existing NYS hospital regulations by specifying the rights of pregnant women and new mothers to be informed about the benefits of breastfeeding, to receive specified maternity care, and to receive support from healthcare providers and healthcare facilities during pregnancy, after delivery, and after discharge and provides a toll-free number to call if a maternity care facility has not honored these rights. The legislation also added new requirements. For example, a hospital must respect a mother's decision to have her baby not receive any pacifiers. The American Academy of Pediatrics recommends pacifier use for infants up to the age of 1 year, when they are placed for sleep, as a potential way to reduce the risk of sudden infant death syndrome.⁶ However, for breastfeeding infants, pacifier use should be delayed for 3–4 weeks, until breastfeeding is well established.⁷

NYS Model Hospital Breastfeeding Policy

The NYS Model Hospital Breastfeeding Policy was developed in late 2010 and finalized in February 2011. Model Policy components are derived from the state hospital regulations (NYCRR), state law (BFMBR), or both, with law superseding regulation when there are differences. The NYS Model Hospital Breastfeeding Policy also incorporates additional recommendations from the Ten Steps,⁵ the Academy of Breastfeeding Medicine,⁸ Baby Friendly USA, Inc.,⁹ and the United States Breastfeeding Committee.¹⁰ The NYSDOH cannot require that hospitals include recommendations not specified in the NYCRR or BFMBR, but hospitals are strongly encouraged to include the recommended components in their hospital breastfeeding policies.

Review, feedback, buy-in

The NYS Model Hospital Breastfeeding Policy was presented to the NYS Breastfeeding Partnership Team, which includes breastfeeding experts across NYS who have an influential role in the improvement of breastfeeding support, promotion, and practice in NYS. Members were offered the opportunity to provide suggestions and revisions prior to the distribution of the document.

The NYS Model Hospital Breastfeeding Policy was also critically reviewed by staff from the NYSDOH Offices of Public Health and Health Systems Management, the Division of Legal Affairs, and the Public Affairs Group to ensure compliance with the intent and language of the BFMBR and NYCRR.

Results

Review of NYS hospitals' breastfeeding policies

All NYS hospitals that provided maternity care services in 2009 (n=139) submitted a copy of their written hospital breastfeeding policy and supporting documentation for review. Based on the NYCRR coding method described, the number of the required components present in hospitals' written breastfeeding policies ranged from 3 to 29 (Fig. 1). On average, the hospital policies included 19 (59%) of the 32 required components. Although 104 (75%) hospital policies contained more than half (at least 17) of the required components, only 24 (17%) hospital policies contained three-quarters (25 or more) of the required components. No hospital policy contained all 32 required components.

FIG. 1.

Distribution of New York State hospitals providing maternity services (n=139) by the number of required components (n=32) included in their hospital breastfeeding policy.

The Ten Steps were operationalized by matching NYCRR-required components to their corresponding Ten Steps (Table 1). These criteria were used to determine whether a hospital's breastfeeding policy included each of the Ten Steps. The Ten Steps were well represented in the hospital breastfeeding policies, but no single Step was included in every hospital policy, nor did any hospital policy include all of the Ten Steps. Although all hospitals had a written breastfeeding policy, only a few hospitals (n=19, 14%) had written procedures to ensure dissemination or communication of the policy to staff. Although the NYCRR do not make any mention of pacifiers during a newborn's hospital stay, more than half (n=83, 60%) of hospital policies restricted their use.

Dissemination of NYS Model Hospital Breastfeeding Policy

At the beginning of February 2011, the final NYS Model Hospital Breastfeeding Policy was sent by secure transmission (NYSDOH Health Commerce System intranet) to the leadership at all NYS hospitals that provided maternity care services (in February 2011, n=135). In addition, the document was sent by e-mail to the individual who had been identified as “most knowledgeable about breastfeeding” at each hospital. The Model Policy and an Implementation Guide are available on the NYSDOH public Web site.^11,12

Discussion

This was the first, comprehensive collection and review of written breastfeeding policies in NYS hospitals. All (100%) of hospitals submitted their policies for review. A systematic, well-defined, transparent method of review was developed and vetted through the NYSDOH. This review found wide variation in the comprehensiveness of the hospital policies. Having a comprehensive written policy is no assurance that the policy is, in fact, translated into practice. However, it is generally accepted that a written policy is a first step in ensuring implementation into practice, communicating to staff, and supporting the sustainability of policy and practice.

There are no published studies evaluating the strength or comprehensiveness of breastfeeding policies in all hospitals or facilities providing maternity care services in any other state. The national survey of Maternity Practices in Infant Nutrition and Care (mPINC) asks staff at maternity facilities to estimate the frequency of maternity care or infant feeding practices.¹³ However, this survey does not report on the presence of written hospital policies requiring those practices. The responses are aggregated to provide state-level estimates of breastfeeding support at maternity facilities. The mPINC survey does not include the granularity or specificity for individual hospitals in NYS and in 2009 had an 82%, compared with 100%, response rate for this hospital policy review.

Several states have undertaken efforts to improve breastfeeding support by developing voluntary reporting systems, based on the Ten Steps (Texas Ten Step Program¹⁴), or a subset of the Ten Steps (Colorado Can Do 5¹⁵ and Arizona Baby Steps to Breastfeeding Recommendations¹⁶). Through the Baby-Friendly Hospital Initiative, hospitals throughout the United States can voluntarily apply for a comprehensive evaluation of their hospital breastfeeding policies and practices to be certified that they are providing optimal level of care to support breastfeeding and thus be designated as a Baby-Friendly Hospital. In 2009, when NYS hospital policies were collected, two hospitals in the state were certified as Baby-Friendly. As of March 2012, there were four and 129 Baby Friendly Hospitals in NYS and the United States, respectively.¹⁷ With increased attention and with support from the Centers for Disease Control and Prevention, many hospitals throughout the country are working to improve hospital policies and maternity care practices to be consistent with the Ten Steps, and many have voluntarily decided to participate in the Baby-Friendly Hospital Initiative.

In 2009, NYS became the second state, after California, to pass legislation—the BFMBR—that specifically applies to healthcare providers and to maternity healthcare facilities, requiring them to ensure that pregnant women and new mothers are provided with the maternity care and support necessary to support successful breastfeeding.^3,18 The California law requires the Department of Public Health to provide training to appropriate hospital staff on hospital policies and recommendations to promote exclusive breastfeeding, with priority given to hospitals that have exclusive breastfeeding rates in the lowest quartile (25%) in the state.¹⁸ The impact of the NYS legislation has yet to be determined, but it reflects increased support in the state for efforts to improve hospital breastfeeding policies and practices.

Only one other state health department has developed a Model Hospital Breastfeeding Policy—the California Department of Public Health. The Department has also developed a toolkit that provides hospitals with recommendations and resources to aid in implementing the policy.¹⁹

Conclusions

The NYS Model Hospital Breastfeeding Policy sets a new standard, not just for NYS, but for all hospitals that provide maternity care services in the United States, by being based on the most current recommendations of expert breastfeeding groups, which are based on the best possible evidence.^8–10,20 A limitation of this study is that while a written policy is often recommended as the first step to promote key practices and procedures, there is no guarantee that the policy will be implemented or enforced. Despite NYS regulations requiring key components, many of these were not included in the written hospital breastfeeding policies. A better understanding of the reasons for the wide variation in hospital breastfeeding policies is needed. Research is also needed to identify best practices to facilitate translation of these policies into systems changes and fully implemented practices.

Next steps in NYS include providing individual feedback for each hospital's policy review to hospital staff and administrators. In addition, efforts are ongoing to improve the quality of care delivered to pregnant women and new mothers to increase promotion, support, and protection of breastfeeding in the hospital setting and beyond. However, to fully realize breastfeeding as the norm, additional efforts are needed throughout the healthcare system, in worksites, and in the broader community. Research is needed to better understand the many determinants of breastfeeding success and how to best support women, infants, and families, to improve breastfeeding metrics in NYS and elsewhere.

Acknowledgments

The New York State Model Hospital Breastfeeding Policy and Implementation Guide were developed by New York State Department of Health and endorsed by the New York State Breastfeeding Partnership Team. We thank Patricia Waniewski, M.S., Marilyn Kacica, M.D., M.P.H., Kevin Leadholm, M.P.H., Sara Bonam Welge, M.S., Eileen Fitzpatrick, M.P.H., the New York City Department of Health and Mental Hygiene, and Members of the New York State Breastfeeding Partnership Team. This work was supported, in part, by the Centers for Disease Control and Prevention (grant DP09-901/3U58DP001963-01S2 and Cooperative Agreement 5U58/DP001414-03) and the New York State Department of Health.

Disclosure Statement

No competing financial interests exist.