When Victoria Munroe first heard that Northampton's Cooley Dickinson Hospital had eliminated its regular drop-in clinic for breastfeeding moms, her first instinct was to get upset. "Of course I was outraged. How can they cut the breastfeeding clinic? That's just so important," said Munroe, an activist and mother of a 3-year-old son.
While it's universally acknowledged that breastfeeding is the healthiest way to feed babies, new moms who run into problems with nursing sometimes can't find the support they need. That can lead them to abandon breastfeeding; it can also add to the numerous stresses already faced by new parents, Munroe said.
Munroe began asking questions and soon found out that Cooley had, in fact, replaced the clinics with other services that staff there felt would better serve new mothers: Instead of the clinics, which had been held three times a week, the hospital began offering a weekly support group led by a lactation consultant; the hospital also offers phone consults and individual appointments, which are billed to insurance companies, for mothers who need one-on-one help. While the changes were made for financial reasons, said Cooley lactation consultant and registered nurse Paula Mattson, she believes they've been changes for the better. The support group allows moms to learn from each other, she said, while individual appointments are an improvement over clinics, where hungry babies and anxious parents would have to wait in line for help.
Munroe, meanwhile, brought the issue to MomsRising, the Amherst-based activist group she helped found a couple of years earlier (see sidebar). Discussing the matter with others in the group, she said, she realized she didn't really know how to evaluate the hospital's changes. "How am I supposed to figure out if the services are better or not?" Munroe said. "I don't know what a hospital should have for breastfeeding support."
Then the MomsRising members discovered the Baby-Friendly Hospital Initiative, an international program that sets standards for hospitals in supporting nursing mothers, with the goal of boosting breastfeeding rates. Two years ago, MomsRising, concerned about the lack of midwifery care at Cooley Dickinson's childbirth center, worked with the hospital to establish a midwifery center. With that experience under its belt, the group is now taking on an even more ambitious effort: persuading CDH and other area hospitals to undertake the rigorous process of being certified "Baby-Friendly."
This week, MomsRising and the Pioneer Valley Breastfeeding Task Force hosted a forum where officials from local hospitals were invited to hear from experts about how to make their facilities Baby-Friendly—and to receive the clear message that many of the mothers they serve want to see them take the plunge.
"I am so excited and proud to be involved in a effort that is driven by mothers," said Tanya Lieberman, a lactation consultant and member of the Breastfeeding Task Force. "I wouldn't be surprised if this is the first time that the push for Baby-Friendly has come from families in the community. Families are the customers of our hospitals, and this event sends a message that they want to be supported in their intention to breastfeed."
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There's extensive evidence of the health benefits of breastfeeding. According to the American Academy of Pediatrics, breast milk offers babies protection against a host of infectious diseases (including potentially fatal diseases such as bacterial meningitis and diarrhea), is linked to reduced rates of SIDS, diabetes, asthma and certain cancers, and enhances cognitive development. Breastfeeding is also linked to quicker post-partum recovery and reduced rates of breast and ovarian cancers for mothers.
Breastfeeding also offers significant financial benefits, both to families who don't have to pay for costly formula, and to society as a whole. " These benefits include the potential for decreased annual health care costs of $3.6 billion in the United States," as well as savings to WIC and other public assistance programs, and lowered rates of workplace absenteeism for parents, the AAP noted in a 2005 policy statement. Nonetheless, breastfeeding rates in the U.S. still fall below what health experts would like to see.
There has been positive movement: According to a 2008 CDC report, 77 percent of new moms initiated breastfeeding at birth, an increase of 36 percent from 1993-94. But those initial efforts too often are not sustained. Another CDC report looking at babies born in 2004 found only 31 percent were being breastfed at three months (far short of a government-set goal of 60 percent), and only 11 percent at six months (versus a government goal of 25 percent). The AAP recommends babies be exclusively breastfed until six months, then breastfed along with other foods until at least the age of one, "and beyond for as long as mutually desired by mother and child."
The Baby-Friendly Hospital Initiative hopes to boost those numbers. The international program, a joint effort of the World Health Organization and UNICEF, established strict criteria for hospitals and birth centers to follow to best support breastfeeding moms. Hospitals that successfully adopt the 10-step program receive the Baby-Friendly designation.
Those steps include having a written breastfeeding policy, which staff are trained to implement, and providing new moms with breastfeeding information and assistance. Infants born at Baby-Friendly hospitals can receive no food or drink other than breast milk, unless medically indicated, and must be allowed to "room in" with their mothers to make nursing easier.
According to UNICEF, more than 15,000 hospitals and birth centers in 134 countries have received the designation, resulting in markedly improved breastfeeding rates. In Cuba, where the majority of hospitals are certified Baby-Friendly, breastfeeding rates for infants tripled in just six years. In China—home to more than 6,000 Baby-Friendly hospitals—exclusive breastfeeding rates rose from 29 percent to 68 percent in rural areas, and from 10 percent to 48 percent in cities, over a two-year period.
In the U.S., the stats are less impressive—at least so far. Only 79 U.S. hospitals and birth centers are Baby-Friendly, according to Baby-Friendly Hospital Initiative USA, which is based in East Sandwich. Only one Massachusetts facility—Boston Medical Center—has the designation.
But that could change soon, noted Liz Westwater, project manager of BFHI USA, which evaluates facilities seeking the designation. In 2008, she said, BFHI USA assessed 16 programs, twice the number it had the previous year. And, she said, the organization is on track to evaluate at least that many this year. Typically, she said, it takes 18 months to two years to complete the process.
"People are coming around more and more to understanding and embracing the concept of breastfeeding as being the best thing for babies and moms as far as health outcomes," Westwater said. Hospitals, meanwhile, are recognizing the cost savings associated with higher breastfeeding rates.
Four Massachusetts hospitals are currently in the process of applying for the Baby-Friendly designation, according to Westwater. All four are in the eastern part of the state, she said, so she's "thrilled" to see the local campaign to bring western Mass. hospitals into the program. "We're excited to see this kind of organizing," said Westwater. "It's very impressive."
And, she added, it's fitting that mothers are leading the campaign. "They're the consumers of the services, so they should ask for what they want," she said.
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At least one local hospital is listening. Mattson, the Cooley Dickinson lactation consultant, said her hospital has already begun the lengthy process of becoming Baby-Friendly certified.
"We're a community hospital, and I think we can set an example, that the community leads, and their concerns need to come first," Mattson said. The hospital has a recent track record of working with community members, opening its midwifery center in response to input from local families. Cooley's midwifery saga also underscored how consumer-driven healthcare is becoming; during the months the hospital didn't have midwifery services, it saw nearby hospitals that did—Holyoke Hospital, Baystate—aggressively marketing to its potential patient base of expectant mothers.
Mattson expects the Baby-Friendly Initiative to be embraced in the Valley. "This is a wonderful area for breastfeeding," she said, noting that 80 percent of new moms at Cooley initiate breastfeeding. And, she said, the hospital already meets a number of the BFHI criteria, such as allowing babies to "room in" with their moms.
Still, becoming certified is not easy or cheap. Mattson expects it to take about two years for Cooley to complete the process, and she estimates the hospital will pay several thousand dollars in filing fees and others costs, such as paying for a BFHI USA staffer to come to review the hospital at the end of the process. (BFHI also works with applicant hospitals, answering questions and providing technical support as they work toward getting the Baby-Friendly designation.)
There are also costs associated with implementing the 10 steps. For Cooley, Mattson said, one of the most expensive will be the 18-hour course on lactation assistance, which will be required of all hospital staff who have contact with newborns. While many Cooley staffers already have lactation training, she said, more will need to be trained, and they all need to complete a course approved by BFHI USA.
Cooley will also take a financial hit when it stops accepting free samples from formula companies, as required under the BFHI criteria. This is a highly controversial practice; breastfeeding advocates cite studies showing that new mothers are less likely to nurse their babies when they're given formula samples. There are also ethical questions raised when hospitals essentially serve as a marketing arm for corporations—especially ones that are selling a product recognized as medically inferior to breast milk.
Cooley, like many hospitals, accepts free formula from the manufacturers, to be given to babies whose mother can't or chooses not to nurse. The formula makers also provide hospitals with "gift bags" for new moms, which typically contain formula samples and coupons, and diaper-bag items like ice packs. At Cooley, Mattson said, the formula-filled bags are only given to families who are using formula; breastfeeding moms get the same bag, minus the formula and coupons. These bags are verboten under BFHI; as the hospital begins implementing the 10 steps, Mattson said, "the bags will go away." (Almost half of Massachusetts hospitals have already stopped giving away formula-company gift bags, noted Lieberman, of the Breastfeeding Task Force.)
Giving up the free-formula habit is a hard step for many hospitals seeking Baby-Friendly certification, said Westwater (although it's certainly not the only one; some hospitals, for instance, find it hard to implement the "rooming in" step if their birth centers have semi-private rooms, she said). Westwater recommends hospitals save that step for last, when the financial hit they take when they stop accepting free formula can be offset by the savings realized by implementing the other steps.
Cooley, Mattson said, doesn't intend to "shove breastfeeding down [the] throats" of families who use formula. "We will support every family that comes to Cooley Dickinson," she said.
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Going Baby-Friendly poses another, less concrete challenge: getting out the word about what the designation means. "It will be important for the public to understand what Baby-Friendly is and what it isn't," Mattson said.
Babies born at a Baby-Friendly hospitals can still be fed formula if needed (although the cost of the formula will be included in the patient's bill, just like hospital meals and medications). Some people, Westwater said, mistakenly think formula is completely banned at Baby-Friendly hospitals, or that families have to bring their own from home. "Obviously, that would be kind of crazy," she said.
It was the misconceptions about BFHI that prompted MomsRising and the Pioneer Valley Breastfeeding Task Force to organize an informational event for local hospitals. "We decided to take an educational approach," said Munroe. While MomsRising initially took up the project in response to the changes in Cooley's lactation services, she said, the group soon decided to take a broader approach, encouraging all hospitals in the area to become Baby-Friendly.
Organizers invited lactation consultants, childbirth educators and administrators from area hospitals to the event, where Westwater was scheduled to explain BFHI and the certification process. Organizers also asked families to talk about their experiences with breastfeeding support at area hospitals. In addition, Dr. Bobbi Phillips of Boston Medical Center was scheduled to talk about the process of becoming Baby-Friendly.
BMC's experience can be an inspiration to other hospitals, Westwater noted. It's a large urban hospital that serves a very culturally and economically diverse demographic, "and they managed to overcome the different barriers," she said.
Westwater is optimistic the initiative will be embraced in the progressive Valley. "My hope is every hospital in Western Mass. will file their letter of intent" to get the designation, she said.
Bringing local hospitals together to learn about the Baby-Friendly program could inspire a collaborative approach, with interested hospitals turning to one another for advice and support as they go through the certification process. Or it could inspire a sense of competition, as hospitals realize that if they don't pursue the designation, they could lose patients to places that have.
"I think you could argue that since moms typically don't know about Baby-Friendly, and as a result it doesn't typically influence their choice of hospitals, there's less incentive to make the investment in becoming certified," Lieberman said. "But I think that may change in this area. Since mothers are the ones advocating for it, it's possible that Baby-Friendly will gain some currency among families looking for a place which will support breastfeeding."
