Policies and practices related to breastfeeding in massachusetts: hospital implementation of the ten steps to successful breastfeeding.

BACKGROUND: Hospital policies and practices related to breastfeeding may have long-term health effects. The Ten Steps to Successful Breastfeeding (WHO/UNICEF) provide an evidence-based standard, which may be used to assess individual hospitals. We assessed implementation, and factors related to implementation, of the Ten Steps in Massachusetts hospitals. METHODS: We surveyed postpartum nurse managers at 43 (88%) of the 49 Massachusetts maternity hospitals by telephone. Survey items characterized hospital policies, breastfeeding education, and support practices. We classified hospital implementation of the Ten Steps as high, moderately high, partial, or low and used Massachusetts Department of Public Health hospital data to analyze factors related to implementation. RESULTS: Levels of implementation of the Ten Steps ranged from high to partial. Overall, we classified implementation of 2% of hospitals as high, 58% moderately high, 40% partial, and 0% as low. Hospitals with high/moderately high levels of implementation significantly differed from hospitals with partial implementation with respect to pacifier usage (p=0.0017) and postpartum breastfeeding instruction (p=0.0001). Requirement of a physician order for formula was a statistically significant (p=0.02) predictor of Step 1 implementation but did not reach significance (p=0.14) overall. Acceptance of free formula was significantly associated (p=0.03) with overall Ten Steps implementation. CONCLUSION: Rates of self-reported implementation of the Ten Steps are relatively high in Massachusetts. Step 1 implementation is significantly associated with formula availability, and overall implementation with acceptance of free formula. Continued assessment is needed to confirm these results in larger samples and to examine the relationship of implementation of individual steps, breastfeeding rates, and health outcomes.

Psychosocial stress and neuroendocrine mechanisms in preterm delivery.

This review focuses on the contribution of psychosocial stress to the racial/ethnic disparities in preterm delivery in the United States and addresses the subset of psychosocial stressors that are disproportionately prevalent among minority women. We argue that chronic exposure to poverty, racism, and insecure neighborhoods may condition stress responses and physiologic changes in ways that increase the risk of preterm delivery. Cumulative stressors may impact pregnancy outcomes through several intersecting pathways, which include neuroendocrine, behavioral, immune, and vascular mechanisms. Many of these pathways also lead to chronic disease. It may be useful to consider preterm delivery as a chronic disease with roots in childhood, adolescence, and early adulthood. Like other physiologic systems, the female reproductive axis may be vulnerable to the physiologic "wear and tear" of cumulative stress, which results in preterm delivery.