Published online September 14, 2009
PEDIATRICS Vol. 124 No. 4 October 2009, pp. e793-e802 (doi:10.1542/peds.2009-0430)
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SPECIAL ARTICLE

Closing the Quality Gap: Promoting Evidence-Based Breastfeeding Care in the Hospital

Melissa Bartick, MD, MSca,b, Alison Stuebe, MD, MScc, Katherine R. Shealy, MPH, IBCLC, RLCd, Marsha Walker, RN, IBCLCe and Laurence M. Grummer-Strawn, PhDd

b Department of Medicine, Harvard Medical School, Boston, Massachusetts
a Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
c Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
d Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta, Georgia
e National Alliance for Breastfeeding Advocacy, Weston, Massachusetts

Evidence shows that hospital-based practices affect breastfeeding duration and exclusivity throughout the first year of life. However, a 2007 CDC survey of US maternity facilities documented poor adherence with evidence-based practice. Of a possible score of 100 points, the average hospital scored only 63 with great regional disparities. Inappropriate provision and promotion of infant formula were common, despite evidence that such practices reduce breastfeeding success. Twenty-four percent of facilities reported regularly giving non–breast milk supplements to more than half of all healthy, full-term infants. Metrics available for measuring quality of breastfeeding care, range from comprehensive Baby-Friendly Hospital Certification to compliance with individual steps such as the rate of in-hospital exclusive breastfeeding. Other approaches to improving quality of breastfeeding care include (1) education of hospital decision-makers (eg, through publications, seminars, professional organization statements, benchmark reports to hospitals, and national grassroots campaigns), (2) recognition of excellence, such as through Baby-Friendly hospital designation, (3) oversight by accrediting organizations such as the Joint Commission or state hospital authorities, (4) public reporting of indicators of the quality of breastfeeding care, (5) pay-for-performance incentives, in which Medicaid or other third-party payers provide additional financial compensation to individual hospitals that meet certain quality standards, and (6) regional collaboratives, in which staff from different hospitals work together to learn from each other and meet quality improvement goals at their home institutions. Such efforts, as well as strong central leadership, could affect both initiation and duration of breastfeeding, with substantial, lasting benefits for maternal and child health.

Key Words: breastfeeding • hospitals • maternity • health care quality • quality indicators • quality improvement • health care • infant • newborn

Abbreviations: CDC—Centers for Disease Control and Prevention • BFHI—Baby-Friendly Hospital Initiative • AAP—American Academy of Pediatrics • WHO—World Health Organization • UNICEF—United Nations Children's Fund • P4P—pay for performance • mPINC—Maternity Practices in Infant Feeding and Care • NQF—National Quality Forum • AAFP—American Academy of Family Physicians • HEDIS—Health Plan Employer Data and Information Set

Accepted May 29, 2009.


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