We Did it for the Babies: A Story of Collective Impact
Creating sustainable changes to improve infant feeding practices means sparking a social movement. It means generating a collective response to a complicated question: what is the healthiest way to feed our newborns?
We know the answers to this question vary. A woman’s perspective of what’s best is affected by the knowledge, attitudes and behaviors of the medical professionals, community members and social supports that surround her. And these factors are heavily influenced by age, race and ethnicity, education, employment status and income, where she lives, and a variety of other social determinants of health.
Accomplishing a culture shift often takes a collaborative effort where, over time, energy builds and spreads until there is collective impact. This is what happened in New York during a seven-year quality improvement initiative to improve infant nutrition and health by increasing exclusive breastfeeding and breastfeeding duration among new mothers.
The New York State Breastfeeding Quality Improvement in Hospitals (NYS BQIH) Collaborative began as a pilot program in 2010 with 12 hospitals. By its completion in 2017, 44 hospitals across New York had participated.
“In the first part of Phase II [in the two-phase initiative], we made improvements that have the potential to benefit 16,000 babies,” says Executive Project Director Jennifer Ustianov, MS, BSN, RS, IBCLC. “That is impressive, but what’s more was the momentum this created as many more New York hospitals enthusiastically engaged in the work. By the initiative’s end, these hospitals had implemented evidence based practices that could impact nearly 70,000 babies while supporting more than 31,000 babies to exclusively breastfeed. As the hospitals engaged in making changes in care delivery systems, policies and practices, a collective impact was realized. This work inspired social and cultural awareness and change.”
Thanks to New York’s improved breastfeeding culture, efforts continue past the project’s completion. And critically, the successes in this state provide a framework for shifting the culture of breastfeeding within states across the nation.
Framework for a Culture Shift—Part 1
Shifting staff attitudes within hospitals is key to that framework of change. “Mothers are most successful when they believe that breastfeeding is important and when they feel equipped and supported to succeed,” says Ustianov. “Nurses are strong protectors of the mother-baby dyad. They are also key influencers. Helping ensure nursing buy-in is critical to a new family’s perceptions of breastfeeding and a mothers’ growing confidence in her decision and skill to breastfeed.”
Sharing data can be a powerful method for achieving that buy-in. Initially, we need to create a sense of urgency for change. Skeptics are often more easily convinced by facts and statistics showing the importance of breastfeeding related to the short and long term health benefits for mother and infants (studies show that breastfeeding reduces mothers’ risk of ovarian cancer, for example). And, then as your initiative evolves, regular progress updates on improvements over time can keep hospital staff invested in accomplishing your long-term aims.
Buy-in by administrative and physician leaders is also important. “We made sure that our maternity ward was filled with boards featuring big-impact statistics on breastfeeding,” says Neonatologist Yogangi Malhotra, MD, from Montefiore New Rochelle Hospital. “You couldn’t walk through any floor without seeing data supporting better breastfeeding habits.”
Montefiore New Rochelle also kept all staff informed about their project by sharing announcements at all staff meetings, quality improvement meetings and board meetings. Similarly, St. Catherine of Siena Medical Center (SCSMC) regularly updated a whiteboard in the nurse’s lounge with their hospital’s breastfeeding exclusivity data, keeping all nurses in the loop on their work’s progress.
While stats can go a long way in building momentum, nurses’ hectic schedules may understandably make them less likely to adopt new processes and procedures.
“Recognizing where our nurses needed a little extra TLC with this process went a long way in getting them on board,” said SCSMC’s Neila Hernandez, MSN, RN, CBC, WHNP-BC. “Our lactation consultant became flexible with her schedule, making herself available for all nurses, especially those on the night-shift. We also purchased helpful teaching tools, like puppets for modeling how to help babies latch. Together, these efforts energized our nurses to invest in a pro-breastfeeding culture.”
These efforts worked. At the height of their work, Montefiore New Rochelle had increased exclusive breastfeeding rates from 4 percent to 67 percent. And SCSMC not only increased skin-to-skin post deliveries by almost 38 percent in a year, but they also recently achieved Baby-Friendly designation.
Framework for a Culture Shift—Part 2
Leveraging mother partners is a second critical part of the framework New York built. NYS BQIH mother partners are moms who recently gave birth at one of the participating hospitals and now want to support other mothers and their babies during their breastfeeding journey. Mother partners offer insight into the barriers mothers encounter, provide a voice for mothers’ experience and are trusted breastfeeding ambassadors in their communities.
“Mothers are vital partners for sustainability,” explains NYS BQIH’s Family Faculty Lead Rebekka Henriksen. “They help us work from a foundation of supporting families and meeting their own goals, rather than imposing policy on them. Working from this foundation results in informed families open to change.”
New York leveraged multiple strategies to make the most of mother partners’ time and contributions. Recognizing the importance of peer-to-peer communication, many hospitals developed breastfeeding support groups and Baby Cafés where mothers could drop in to receive individual support on breastfeeding. Mothers also contributed personal stories during prenatal classes and further spread the word by canvassing their communities.
To reach those who may not have been able to attend classes or go to one of the cafés, hospitals recorded and shared mother-partner stories virtually. Similarly, online support groups were important extensions to in-person gatherings.
Together, the accomplishments of the 44 hospitals in this initiative reflect the sustainability of improvements that build off the efforts of others. One hospital working in isolation has limited reach. But, when its progress builds on the work of others and lays the foundation for future improvement efforts, when its work becomes a part of a collective movement, its actions suddenly occupy a much larger stage.
This is what we saw in New York, in an initiative that brought improved breastfeeding care to approximately 25 percent of New York mothers so that they could give their babies the best start possible.
Interested in learning more about improving breastfeeding rates in your state of community? This article offers advice on reaching better breastfeeding outcomes by practicing cultural sensitivity. Or, sign up for our mailing list to stay informed on lessons learned from our on-going initiatives
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In honor of National Breastfeeding Month, we’ve taken time with NICHQ Faculty Expert, Lori Feldman-Winter, MD, MPH, an internationally and nationally recognized expert on breastfeeding nutrition, education and policy, to recognize successes and learn about opportunities for improvement. Her frank description of bias and her passion for promoting gender-equitable social norms have inspired us to continue pursuing sustainable improvements.
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