Guidelines from the American Academy of Pediatrics and World Health Organization recommend exclusive breastfeeding during the first six months of infancy and continued breastfeeding with the introduction of solid foods throughout the first year of life until two years of age or longer.
Although compliance with those recommendations falls short nationwide, significant disparities exist in pockets of the United States when race and ethnicity are factored in. In Ohio, at discharge from the delivery hospital, only 51.2% of infants are exclusively breastfed, compared to the national average of 78%. Broken down further, the rate for Black patients is 35.6% compared to 56.3% for white patients. After discharge, the rate of breastfeeding for the Black, non-Hispanic population has the highest decrease compared to other racial/ethnic groups. Black women are also more likely than most minority groups to provide formula supplementation by two days of life.
Seeing this data, the Nationwide Children's Hospital Primary Care Network (PCN) decided to look further into possible causes for these disparities with patients and take action. PCN has 14 locations providing over 200,000 visits per year. At each location, the payor mix ranges from 50% to 85% Medicaid. The patients speak many languages, with the top five being English, Spanish, Somali, Arabic and Nepali.
During the needs assessment, Black families stated their experience in the birth hospitals and in seeking well care was met with assumptions that the family would choose bottle-feeding or would not be able to overcome typical challenges encountered by new lactating mothers. Further, many of the physicians, nurses and other clinical staff did not feel comfortable providing lactation counseling at the level that was needed for the family. Although care providers did their best to address the issues, factors such as time and lack of expertise left mothers feeling discouraged.
A multidisciplinary team devised a plan to develop and implement structures, processes and supports to address the barriers to sustaining breastfeeding in patients within the PCN. The plan included:
- Supporting learning and development. Multiple education sessions informed teams of their role and the purpose of supporting families. Physicians, nurses, RNs and LPNs are now Certified Lactation Counselor (CLC) trained.
- Increase access to CLC services in clinics. With more trained staff, families have more access and can contact the clinic for phone, virtual and in-person consults. Some providers also expressed more comfort with giving advice during well child exams.
- Make outcomes visible. Aligning the goals of the program with the strategic plan of the organization and goals for population health gives the PCN an opportunity to share their contribution to promoting wellness and keeping children healthy.
- Build infrastructure to support program growth. The program development was supported through the VP’s participation in the hospital quality improvement excellence course, which aims to further develop leaders’ knowledge and skills so they are able to measure, evaluate and improve clinical outcomes using evidence-based methodologies. The support of senior leaders, education, quality improvement and clinical teams allowed for making a clear business case and implementing a program coordinator role that is instrumental to the success of daily operations and future expansion.
After implementing these changes, the team collected data through the electronic medical record, which included mothers’ reports of sustained breastfeeding, both exclusively and supplemental at well child visits and at visits with the CLC. The mothers also shared their experience with the services through patient satisfaction surveys and during outreach at community events.
Mothers are sustaining breastfeeding longer and expressing excitement that they get to communicate with a CLC in their medical home. Furthermore, many of the mothers specifically speak to having a CLC that looks like them and speaks their native language.
One mother stated, “Having a lactation counselor in clinic helped me to know what to do with my baby when it came to breastfeeding. The lactation counselor gave me tips on pumping, latching and peace of mind. It was nice to know what to expect and that I can reach out to her if I had any questions.”
The greatest success has occurred at the PCN locations that have dedicated CLC support, with over 60% of babies receiving only human milk as of their two-month well child visit.
Demographics is a confounding factor, but we know that more CLC support is needed. Therefore, as the PCN forges ahead, the best practices are systematically being implemented. The journey to leading best outcomes continues for healthier communities now and into the future.