Policies and Practices in a Cohort of Mississippi Birthing Hospitals During the COVID-19 Pandemic.

Background and Objectives: Guidance around maternity care practices and infant feeding during the COVID-19 pandemic changed over time and was sometimes conflicting. Hospital maternity practices influence breastfeeding, an important preventive strategy against viral illness. Most birthing hospitals in Mississippi are enrolled in CHAMPS, a quality improvement initiative to support breastfeeding and continuously collect maternity care data. The aims of this study were to (1) assess changes to maternity care policies in response to COVID-19, and (2) compare hospital-level breastfeeding, skin-to-skin, and rooming-in rates, at cohort hospitals, before and during the pandemic, overall and stratified by race. Methods: Hospitals responded to a survey on maternity policies in May and September 2020 (Aim 1); hospitals submitted data on breastfeeding and maternity care practices before and during the pandemic (Aim 2). We tested for differences in survey responses using chi-squared statistics and performed an interrupted time series analysis on breastfeeding and maternity care practices data. Results: Twenty-six hospitals responded to the May and September 2020 surveys. Hospitals used different sources to create maternity care policies, and policies differed between institutions. Trends in rates of any and exclusive breastfeeding in the hospital cohort plateaued during the pandemic, in comparison to previous gains, and rates of skin-to-skin and hospital rooming-in decreased. No differences were evident between races. Conclusions: Policies (Aim 1) and practices in the quality improvement cohort hospitals were inconsistent during the COVID-19 pandemic, and changes measured to practices were detrimental (Aim 2). Ongoing monitoring is recommended.

Assessing the impact of a statewide effort to improve breastfeeding rates: A RE-AIM evaluation of CHAMPS in Mississippi.

Communities and Hospitals Advancing Maternity Practices (CHAMPS) is a public health initiative, operating in Mississippi since 2014, to improve maternal and child health practices and reduce racial disparities in breastfeeding. Using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, this study assessed CHAMPS, which used a Quality Improvement intervention at hospitals, and engaged intensively with local community partners. The study team assessed outcomes through quantitative data (2014-2020) from national sources, Mississippi hospitals, community partners and CHAMPS programme records, and qualitative data from focus groups. With 95% of eligible Mississippi hospitals enrolled into CHAMPS, the programme reached 98% of eligible birthing women in Mississippi, and 65% of breastfeeding peer counsellors in Mississippi's Special Supplemental Nutrition Programme for Women, Infants and Children. Average hospital breastfeeding initiation rates rose from 56% to 66% (p < 0.05), the proportion of hospitals designated Baby-Friendly or attaining the final stages thereof rose from 15% to 90%, and 80% of Mississippi Special Supplemental Programme for Women, Infants, and Children districts engaged with CHAMPS. CHAMPS also maintains a funded presence in Mississippi, and all designated hospitals have maintained Baby-Friendly status. These findings show that a breastfeeding-focused public health initiative using broad-based strategic programming involving multiple stakeholders and a range of evaluation criteria can be successful. More breastfeeding promotion and support programmes should assess their wider impact using evidence-based implementation frameworks.

Mississippi CHAMPS: Decreasing Racial Inequities in Breastfeeding.

Mississippi CHAMPS addressed racial inequities in breastfeeding by implementing community and hospital-based practice changes in accordance with the BFHI and by parallel community work.

Breastfeeding supportive practices in European hospitals during the COVID-19 pandemic.

INTRODUCTION: During the first year of the COVID-19 pandemic, international recommendations and guidelines regarding breastfeeding-supportive hospital practices changed frequently. For example, some recommended separation of mothers and infants; others, feeding pumped milk instead of milk fed directly from the breast. Many recommendations were inconsistent or in direct conflict with each other. Guidance from UENPS (the Union of European Neonatal and Perinatal Societies) published in April 2020 recommended rooming in and direct breastfeeding where feasible, under strict measures of infection control, for women who were COVID-19 positive or under investigation for COVID-19. KEY FINDINGS: Our study assessed data from respondents from 124 hospitals in 22 nations, with over 1000 births per year, who completed a survey on practices during the COVID-19 epidemic, as they related to the World Health Organization (WHO) Ten Steps to Successful Breastfeeding, considered to be the gold standard for breastfeeding support. The survey was conducted in the fall of 2020/winter of 2021. Overall 88% of responding hospitals had managed COVID positive mothers, and 7% had treated over 50 birthing women with confirmed COVID-19. The biggest change to hospital policy related to visitation policies, with 38% of hospitals disallowing all visitors for birthing women, and 19% shortening the postpartum stay. Eight hospitals (6%) recommended formula feeding instead of breastfeeding for women who tested positive for COVID-19 or were under investigation, whereas 73% continued to recommend direct, exclusive breastfeeding, but with some form of protection such as a mask or hand sanitizer for the mother or cleaning the breast before the feed. While 6% of hospitals discontinued rooming in, 31% strengthened their rooming in policy (keeping mothers and their babies together in the same room) to protect infants against possible exposure to the virus elsewhere in the hospital . Overall, 72% of hospitals used their country's national guidelines when making policy, 31% used WHO guidelines and 22% UENPS/SIN guidelines. Many European hospitals relied on more than one accredited source. DISCUSSION: Our most concerning finding was that 6% of hospitals recommended formula feeding for COVID positive mothers, a measure that was later shown to be potentially harmful, as protection against the virus is transmitted through human milk. It is encouraging to note that a third of hospitals strengthened rooming in measures. Especially given the emergence of the highly transmissible Delta variant, the situation around postnatal care in maternity hospitals requires ongoing monitoring and may require proactive investment to regain pre-COVID era practices.

Perspectives of Nurses in Mississippi on Implementation of the Baby-Friendly Hospital Initiative.

OBJECTIVE: To describe the experiences and perceptions of Mississippi maternity nurses in hospitals that gained Baby-Friendly designation, including perceived barriers and facilitators to implementation of the Baby-Friendly Hospital Initiative. DESIGN: Descriptive qualitative study using thematic analysis of focus group data. SETTING: Maternity care services of five Baby-Friendly-designated hospitals in Mississippi. PARTICIPANTS: Twenty-two maternity nurses. METHODS: We conducted 90-minute in-person focus groups in which participants described their hospitals' Baby-Friendly experiences. We analyzed focus group transcripts thematically to describe the facilitators and barriers to implementation of the Baby-Friendly initiative. RESULTS: We identified five main themes: The Change Required for BFHI Was Hard, Nurses Felt Empowered by Taking Leadership Roles, Patient Education Was Pivotal to Practice Implementation, Nurses Felt Challenged by Unintended Consequences, and Attitudes Changed From Negative to Positive Over the Course of Adoption. CONCLUSION: Participants from hospitals throughout Mississippi shared similar experiences and cited common facilitators and barriers to achieving Baby-Friendly designation. Participants described the overall process of Baby-Friendly designation as challenging but worthwhile because of the resulting improvements in maternity care, nurses' knowledge, and health outcomes for women and their newborns. Nurses at other hospitals that seek to obtain designation can learn from these experiences to make their own transitions easier.

Addressing Racial Inequities in Breastfeeding in the Southern United States.

BACKGROUND: Race is a predictor of breastfeeding rates in the United States, and rates are lowest among African American infants. Few studies have assessed changes in breastfeeding rates by race after implementing the Ten Steps to Successful Breastfeeding (hereafter referred to as the Ten Steps), and none have assessed the association between implementation and changes in racial disparities in breastfeeding rates. Our goal was to determine if a hospital- and community-based initiative in the Southern United States could increase compliance with the Ten Steps, lead to Baby-Friendly designation, and decrease racial disparities in breastfeeding. METHODS: Hospitals in Mississippi, Louisiana, Tennessee, and Texas were enrolled into the Communities and Hospitals Advancing Maternity Practices initiative from 2014 to 2017 and received an intensive quality improvement and technical assistance intervention to improve compliance with the Ten Steps. Community partners and statewide organizations provided parallel support. Hospitals submitted monthly aggregate data stratified by race on breastfeeding, skin-to-skin care, and rooming in practices. RESULTS: The disparity in breastfeeding initiation between African American and white infants decreased by 9.6 percentage points (95% confidence interval 1.6-19.5) over the course of 31 months. Breastfeeding initiation increased from 66% to 75% for all races combined, and exclusivity increased from 34% to 39%. Initiation and exclusive breastfeeding among African American infants increased from 46% to 63% (P < .05) and from 19% to 31% (P < .05), respectively. Skin-to-skin care after cesarean delivery was significantly associated with increased breastfeeding initiation and exclusivity in all races; rooming in was significantly associated with increased exclusive breastfeeding in African American infants only. CONCLUSIONS: Increased compliance with the Ten Steps was associated with a decrease in racial disparities in breastfeeding.

Weight gain in the first week of life predicts overweight at 2 years: A prospective cohort study.

In formula-fed infants, rapid weight gain during the first week of life is associated with later obesity. To examine the association between weight gain during the first week and overweight at age 2 among infants with various feeding practices and the relationship between exclusive breastfeeding in early infancy and overweight, we enrolled a prospective cohort of healthy mother-infant dyads and followed them for 2 years. We enrolled 450 mother/infant pairs and obtained information on 306 infants at year 2. Weight change during the first week of life and detailed feeding information were collected during the first month of life. Anthropometric measures were collected at 2 years. Overweight was defined as body mass index (BMI) ≥85th percentile for age. At 2 years, 81% had normal weights and 19% were overweight. Maternal pre-pregnancy BMI; infant birth weight; maternal education; and Women, Infants, and Children status were associated with the risk of overweight at age 2. Children who gained more than 100 g during the first week were 2.3 times as likely after adjustment (p = .02) to be overweight at age 2 compared to infants who lost weight. There was no association between feeding type and BMI, but feeding type was significantly associated with change in weight at week 1 and anthropometric measurements at age 2. Infant weight gain in the first week of life is related to overweight at age 2, and exclusively breastfed infants are least likely to gain ≥100 g.

Best Fed Beginnings: A Nationwide Quality Improvement Initiative to Increase Breastfeeding.

BACKGROUND AND OBJECTIVE: In response to a low number of Baby-Friendly-designated hospitals in the United States, the Centers for Disease Control and Prevention funded the National Institute for Children's Health Quality to conduct a national quality improvement initiative between 2011 and 2015. The initiative was entitled Best Fed Beginnings and enrolled 90 hospitals in a nationwide initiative to increase breastfeeding and achieve Baby-Friendly designation. METHODS: The intervention period lasted from July 2012 to August 2014. During that period, data on process indicators aligned with the Ten Steps to Successful Breastfeeding and outcome measures (overall and exclusively related to breastfeeding) were collected. In addition, data on the Baby-Friendly designation were collected after the end of the intervention through April 2016. Hospitals assembled multidisciplinary teams that included parent partners and community representatives. Three in-person learning sessions were interspersed with remote learning and tests of change, and a Web-based platform housed resources and data for widespread sharing. RESULTS: By April 2016, a total of 72 (80%) of the 90 hospitals received the Baby-Friendly designation, nearly doubling the number of designated hospitals in the United States. Participation in the Best Fed Beginnings initiative had significantly high correlation with designation compared with hospital applicants not in the program (Pearson's r [235]: 0.80; P < .01). Overall breastfeeding increased from 79% to 83% (t = 1.93; P = .057), and exclusive breastfeeding increased from 39% to 61% (t = 9.72; P < .001). CONCLUSIONS: A nationwide initiative of maternity care hospitals accomplished rapid transformative changes to achieve Baby-Friendly designation. These changes were accompanied by a significant increase in exclusive breastfeeding.

Implementation of a Donor Milk Program Is Associated with Greater Consumption of Mothers' Own Milk among VLBW Infants in a US, Level 3 NICU.

BACKGROUND: It is unclear whether use of donor milk (DM) changes the provision of mothers' own milk (MOM) to very low birth weight (VLBW) infants in the neonatal intensive care unit (NICU). OBJECTIVES: To determine whether (1) the rates of any MOM and human milk consumption at feeding initiation and discharge and (2) the proportion of VLBW infants who stopped consuming any MOM and human milk during hospitalization changed in the 2 years after versus before implementation of a DM program in a US, inner-city, level 3 NICU. METHODS: We studied VLBW infants admitted to Boston Medical Center in the 2 years before (n = 74) and after (n = 80) implementation of a DM program (June 2011). We used multivariable logistic regression to compare milk consumption at feeding initiation and discharge and Cox proportional hazards to compare the proportion of infants that stopped consuming milk during the hospitalization pre and post our DM program. RESULTS: After adjustment for maternal race, age, insurance, delivery type, gestational age, and birth weight, we found a 6.0-fold increased odds (95% CI, 2.0-17.7) of consuming MOM at discharge and a 49% reduction in the cessation of MOM consumption during hospitalization (hazard ratio [HR], 0.51; 95% CI, 0.28-0.93) in the 2 years after versus before our DM program. CONCLUSION: Implementation of a DM program was associated with greater consumption of MOM throughout hospitalization and at discharge among VLBW infants. Implementation of DM programs may augment support of mothers to provide breast milk in level 3 NICUs.

Bringing Baby-Friendly to the Indian Health Service: A Systemwide Approach to Implementation.

The Baby-Friendly Hospital Initiative (BFHI) increases exclusive breastfeeding. Breastfeeding protects against obesity and diabetes, conditions to which American Indians and Alaska Natives are particularly prone. As part of the First Lady'sLet's Move! in Indian Countryinitiative, the US Department of Health and Human Services' Indian Health Service (IHS) began implementing the BFHI in 2011. The IHS administers 13 US birthing hospitals. There are 5 tribally administered hospitals in the lower 48 states that receive IHS funding, and the IHS encouraged them to seek Baby-Friendly designation also. In the 13 federally administered hospitals, the IHS implemented a Baby-Friendly infant feeding policy, extensive clinician training, and Baby-Friendly compatible medical records. All hospitals also became compliant with the World Health Organization's International Code of Marketing of Breast-Milk Substitutes. Strategies and solutions were shared systemwide via webinars and conference calls. Quality improvement methods, technical assistance, and site visits assisted with the implementation process. Between 2011 and December 2014, 100% (13 of 13) of IHS federally administered hospitals gained Baby-Friendly designation. The first Baby-Friendly hospitals in Arizona, New Mexico, North Dakota, Oklahoma, and South Dakota were all IHS sites; 6% of all US Baby-Friendly hospitals are currently IHS hospitals. One tribal site has also been Baby-Friendly designated and 3 of the 5 remaining tribally administered hospitals in the lower 48 states are pursuing Baby-Friendly status. Baby-Friendly Hospital Initiative implementation systemwide is possible in a US government agency serving a high-risk, underprivileged population. Other systems looking to implement the BFHI can learn from the IHS model.

Breastfeeding and coffee consumption in children younger than 2 years in Boston, Massachusetts, USA.

BACKGROUND: Although introduction of inappropriate foods and liquids in early childhood and their association with breastfeeding is commonly reported in US children, coffee use in very young US children and its association with breastfeeding is not. OBJECTIVES: This study aimed to determine the proportion of 1- and 2-year-olds in an urban population consuming coffee, their rate of consumption, and predictors of consumption, including breastfeeding status. METHODS: We used data from a prospective cohort study on infant weight gain and diet, and body mass index at age 2. We used bivariate analyses to examine variables associated with coffee consumption at 1 and 2 years and multivariate logistic regression to control for variables of interest. RESULTS: This study included 315 mother-infant dyads. At 1 year, the rate of coffee consumption reported was 2.5%; at 2 years, it was 15.2% and average daily consumption was 1.09 oz (range, 0.01- 4.00 oz). The only characteristic associated with coffee consumption at 1 year was breastfeeding at 1 year (P = .0275), which did not remain significant after controlling for confounding variables. Variables significantly associated with coffee consumption at year 2 were lower maternal education (P = .0016), non-US maternal place of birth (P = .0015), maternal Hispanic ethnicity (P < .0001), infant female sex (P = .0495), and receiving any breast milk at 1 year of age (P = .0189). After multivariate logistic regression, maternal Hispanic ethnicity (P = .0139) and infant female sex (P = .0371) remained significant. CONCLUSION: Coffee consumption is not uncommon among toddlers in Boston, Massachusetts, USA. After controlling for possible confounding factors, maternal ethnicity and infant sex were significantly associated with this practice.