Breastfeeding Initiative
Chelsea Oberheim & Heather Rush
Lakeview College of Nursing
Nursing Leadership and Management
Professor Tina Flemming
February 13, 2013

Breastfeeding Initiative
	Inpatient obstetric services at Carle Foundation Hospital are focused on providing nursing care and education to the new family unit. The department’s hours of operation are 24 hours a day 7 days a week. The Labor and Delivery unit’s primary patient population consists of pregnant women, who are in labor, with pregnancy complications, or with other medical comorbidities that are caused or may affect the pregnancy. To ensure that exceptional care is given on the unit, there are several different practitioners involved in the care of the L & D patients. Staff nurses consist of licensed Registered Professional Nurses.  These RN’s are proficient in basic and advanced life support and other unit specific mandated competencies. The RN’s are the primary care givers to the patients while they are clients in L & D. RN’s use the nursing process, evidence based research, technology, and the resources within their facility to care for their patients. They also work to ensure the upholding of the facilities philosophies, values and standards of care. Unit assistants are business professionals that help the nurse by handling medical and business information and facilitating communication with visitors, other departments, and employees. The unit assistant position is specific to L & D department. Health care technicians assist the nurse with direct patient care. HCT also facilitate charting, ordering supplies, stocking units with materials. HCT work in collaboration with the RN’s to ensure a safe patient environment with integration of patient support. Additional staff that would be utilized to care for L & D patients would include; dieticians, social workers, pharmacists, patient educators, pastoral care, bereavement counselors, anesthesiology, respiratory therapy, lab and x-ray technicians. 
	Unit priorities or goals deemed of importance are written by the Director of L & D with the opinions of medical and unit staff. These priorities are then approved by the nurse executive for the unit. The priorities for the unit are then reviews on an 18-month basis along with the unit structure.  The delivery of safe, effective, and appropriate care is one of the most important priorities for the L & D unit since they care for a high majority of high risk obstetrics patients.  The unit also has a focus on the allocation of resources for patients and the collection of data from staff and patients for continuous improvements on the unit, these goals correlate along with the mission statement of the facility. Along with these priority goals the unit is concerned with cost containment and their fiscal responsibility, the unit’s goal is to provide the best quality of care in a cost effective way. All of these aspects of care are monitored on the L & D unit. This QI project is a combination of the aspects of care mentioned. This initiative encompasses these aspects by encouraging maternal-fetal bonding and it facilitating proper nutrition administration for the neonate. 
	“The importance of breastfeeding as a national health goal is evident by the inclusion of five breastfeeding goals in Healthy People 2010” (DiFrisco, E., Goodman, K., Budin, W., Lilienthal, M., Kleinman, A., & Holmes, B., 2011, p. 29). This study was conducted in an urban hospital that adopted the Baby-Friendly Initiative using a descriptive survey design which could be done online or via telephone. 47 participants used the telephone and 66 used the internet web site Survey Monkey to participate. This survey consisted of 28 questions. The questions were “based on a review of literature and validity was determined by a panel of experts” (DiFrisco et al. 2011, p. 31). 60.2% of the participated reported breastfeeding within the first hour.  “Mothers who reported breastfeeding within the first hour of birth were significantly more likely to be exclusively breastfeeding at 2 to 4 weeks after discharge (X2 [1, N=96] = 8.046, p= .005) than mothers who did not breastfeed within the first hour of birth (Difrisco et al. 2011. P. 32). Limitations of this study included the fact that the participants were “predominately middle class and the sample was self-selected” (DiFrisco et al. 2011 p. 33). One recommendation for a future studies includes using a more diverse socioeconomic population. This article was useful because she shows how important the initiation of breastfeeding within the first hour of birth. This article was current with a publishing date of 2011, peer reviewed, and had an extensive literature review which included articles ranging from 1990 – 2010. The majority of used articles are current within the last 6 years. This literature shows no gaps in knowledge which makes it a reliable source. 
The second article used for this QI project took at a look at breastfeeding mothers and the factors that cause them to breastfeed longer. They identified five hospital practices that would benefit breastfeeding mothers and assist them in increasing the duration that they breastfed. “This study used data from the Colorado Pregnancy Risk Assessment Monitoring System (PRAMS), which is an ongoing, statewide, population-based surveillance system designed to identify and monitor behaviors and experiences of women before, during, and after pregnancy” (Murray, E., Ricketts, S., Dellaport, J., 2007, p. 202). Approximately 3000 mothers received the mailed PRAMS questionnaire and the response was 70% respectively. Mothers were asked in the hospital they delivered in practices the “Ten Steps for Successful Breastfeeding”. An interesting fact noted in the research was of “the five hospital practices that resulted in higher breastfeeding duration were breastfeeding in the first hour after birth” (Murray, E., et al. 2007, p. 205). Of the mothers surveyed 85% of them had breastfeeding initiation within the first hour, and of that number 48% continued to breastfeed past 13 weeks postpartum. This study was helpful because it showed that “the strength of the five hospital practices (including initiation of breastfeeding within one hour) provided the greatest increase in breastfeeding duration” (Murray et al. 2007, p. 209). Some limitations of this study include the use of a secondary survey, the reliance on maternal self-report, and some questions not being specific enough. Another limitation was the short duration for data collection which doesn’t provide much information past a period of 4 months. In conclusion, this study proves that “widespread implementation of such successful practices should have a positive effect on breastfeeding duration rates” (Murray et al. 2007, p. 210). This article was peer reviewed and current with a publishing date of 2007. This article had an extensive literature review with articles ranging from 1996 – 2007. There does show some gap in knowledge since the articles are older in age, but they were well reviewed sourced none the less and provided adequate information for the research being done. 
With the big push for early breastfeeding the third study used as a resource decided to look at the question of whether a structured program would benefit a breastfeeding mother rather than a non-structured breastfeeding program. This study used two independent reviewers who critically reviews literature published from 1992-2010 which was found using extensive search tactics such as MEDLINE, CINAHL, Cochrane Library, and several others. Qualitative and quantitative studies were both used. A total of 990 articles were reviewed and 26 of those were used for the study.  “Because of clinical and methodological heterogeneity of study designs, it was not possible to combine the studies or individual outcomes in meta-analysis” (Beaker, S., Pellowe, C., Dykes, F., Schmied, V., & Bick, S., 2012, p. 143-144). This study was helpful because if reported “most studies found an improvement in initiation of breastfeeding following introduction of a structured programme compared with no programmes” (Beaker, S. et al. 2012, p. 158). These structured programmes included the “Baby-Friendly Hospital Initiative underpinned by the Ten Steps to Successful Breastfeeding” (Beaker, S. et al, 2012, p. 141), which implements breastfeeding of neonate within one hour of birth. This article gave a copious amount of information about the duration of breastfeeding and the correlation with early initiation. The article was peer-reviewed and had an extensive literature review. Article ranges from years of 1998 – 2010, with the majority being from the last 6 years respectively. The literature reviewed shows no gaps in knowledge. 
“Veterinarians know that separation of an animal mother and her newborn in the first minutes and hours after birth may compromise that health and survival of the newborn” (Elliot-Carter, N., & Harper, J., 2012 p. 291). With this knowledge, a woman’s specialty hospital in south Louisiana which delivers close to 8,000 babies per year wanted to look at this concept at it related to human neonates. The facility started the process to create and facilitate new care delivery model which focused on  promotion of maternal-infant bonding ad breastfeeding soon after the neonates’ cesarean birth. The facility for years followed the tradition of separating mothers and their neonates after cesarean birth. “This separation of mothers and infants delays critical bonding, skin-to-skin contact, and breastfeeding” (Carter, et al. 2012 p. 292). Having motivation such as; for the facility to become more “baby friendly”, increasing patient requests for no separation, a desire to stay competitive in the community, the commitment to maintain status as a leader in obstetrics, nurses started looking at ways to initiate changes. Another reason to facilitate mother-neonatal rooming together is that “early breastfeeding has been shown to positively impact the duration of breastfeeding” (Carter et al. 2012, p. 292). Before implementation of the finalized protocol, two trial runs were performed on separate days for scheduled cesarean section patients. Upon complete enforcement of the changes the outcome have been positive. “Before implementing this change, an average of 301.58 (42 percent)” of neonates would have been separated for a period of time after birth, this has dropped to an “average of 26.33 (3.7 percent) of neonates being separated from their mothers after birth (Carter et al. 2012 p. 295). This research show a significant decrease after implementation of the protocols issued. This article was substantial to review, it was peer reviewed and although a short article had several literature reviews. Articles ranged from 2004 – 2010, which means there was no gap in knowledge and gave current research to support the cause. 
	Although early skin-to-skin contact between neonate and mother is not yet a standard of practice at birthing facilities, it does prove to be beneficial to neonate and mother in several different ways. “The hour after birth had been described as a critical period for emotional development, attachment, breastfeeding initiation, and infant neurological development” (Haxton, D., Doering, J., Gingras, L., & Kelly, L. 2012, p. 222). According to Haxton et al. 2012, “newborns engaged in skin-to-skin contact have been shown to have improved sickling reflexes, to breastfeed more easily immediately after birth”, which is one of just a few benefits of this practice. The article takes a look at a nurse initiated study on the effects of exclusive breastfeeding, where the target time was one hour after birth. The clinical implementation was correlated with Iowa Model of Evidence Based Practice to Improve Quality to ensure consistency with the process. This systematic model works as a framework that can guide the nurses to “improve patient outcomes, enhance nursing practice, and monitor health costs” (Haxton et al. 2012, p. 223). The goal of the facilitating implementing the Iowa model was to exceed the Healthy People 2010 initiative of 75 percent of breastfeeding mothers being initiated which would reduce the use of formula by 20 percent. Before the model could be implemented the approval from the Best Practice Committee had to be obtained. After intense discussion the model was actively implemented. Upon execution of the policy it was found that “this project was a significant practice change for  L & D nurses, since their standard of practice prior to this was focused on the completion of tasks rather than promoting an ideal natural environment for the newborn” (Haxton et al. 2012, p. 225). This project forced the nurses to take a step back from their normal practice and look at the situation outside of the box. The previous standard of care at this facility was to bath the neonate, administering vitamin K and eye ointment, and obtain measurements before handing over the neonate to the parents. Research was obtained that ensured that prolonging the neonatal interventions would cause no harm to the neonate, but would ensure skin-to-skin contact and ultimately breastfeeding initiation within the first hour more tangible. After the project was piloted and fully engaged the birthing center saw and increase of breastfeeding initiation from 74 percent to 84 percent, which substantially fulfilled their goal of obtaining the Healthy People 2010  standard of 75 percent. By using evidence-based practiced the nurses were about to implement practices that would benefit the health of patient and improve the birthing experience in their facility. This article was current and from a peer reviewed journal. It had an extensive literature review which included article from 2006 – current. The use of this information shows no gap in knowledge and ensures proper resources were used for research. 
	There are several specific indicators that can be identified in the practice of initiating breastfeeding within the first hour of neonatal birth. Patient outcomes that can be observed include; seeing the mothers breastfeeding, watching the neonates latch on to the breast, and the touch of assisting with the facilitation of skin-to-skin contact after delivery. Nurses would be documenting the time of breastfeeding initiation, whether it was successful or not, and if interventions were needed. Other information that would need documented would be the duration of the feed, how mother and neonate responded to the breastfeeding, and were all goals that were set obtained, if not why. High quality care can be evaluated with observation, communication, post-care surveys. It will be know that high quality care has been given if it is observed with the satisfaction of the client, hear with the communication of positive feedback, and felt with the heartwarming success stories of the clients of the L & D department. The indicators are derived from the standards of care which will be exemplified by exceptional care given. Indicator quality can be describes as ensuring patient safety and happiness, while keeping with the philosophies, values, and standards of the facility.

References
Beaker, S., Pellowe, C., Dykes, F., Schmied, V., & Bick, S. (2012). A systemic review of 
structured compared with non-structured breastfeeding programmes to support the 
initiation and duration of exclusive and any breastfeeding in acute and primary health 
care setting. Maternal and Child Nutrition 8, 141-161. 
DiFrisco, E., Goodman, K., Budin, W., Lilienthal, M., Kleinman, A., & Holmes, B. (2011). 
associated with exclusive breastfeeding 2 to 4 weeks following discharge from a large, 
urban, academy medical center striving for baby-friendly designation. The Journal of 
Perinatal Eduation 20(1), 28-35. doi:10.1891/1058-1243.20.1.28
Elliott-Carter, N., & Harper, J. (2012). Keeping mothers and newborns together after cesarean: 
How one hospital made the change. Nursing for Women’s Health, 16(4), 291-296. doi: 
10.111/j.1751-486X.2012.01747.x
Haxton, D., Doering, J., Gingras, L., & Kelly, L. (2012). Implementing skin-to-skin contact at 
birth using the Iowa Model: Applying evidence to practice. Nursing for Women’s Health, 
16(3), 220-230. doi: 10.1111/j.1751-486X.2012.01733.x
Murray, E., Ricketts, S., Dellaport, J., (2007). Hospital practices that increase breastfeeding 
duration: Results from a population-based study. Birth 34(3), 202-211.