Miriam Labbok, MD, MPH, FACPM, IBCLC, FABM Carolina Global Breastfeeding Institute Professor Director, CGBI and Meghan Shanahan, MPH, PhD Which of the “Ten Steps to Successful Breastfeeding” has the greatest impact in the US? in Session , A Quiet Breastfeeding Revolution: Taking The Ten Steps across the USA, Wednesday, November 10, 2010, 12:30 PM-2:00 PM

No conflict of interest Acknowledgements –Anonymous Donor –Carolina Global Breastfeeding Institute Anonymous Donor –Staff, Students and Affiliated Faculty of CGBI Learning Objectives: –Present the approach of the CGBI –Describe the 10 Steps to Successful Breastfeeding –Discuss the state-level association of individual Steps with breastfeeding outcomes

Carolina Global Breastfeeding Institute --CGBI-- Founded in 2006 –endowed professorship and scholarship UNC Department of Maternal and Child Health and WHO Collaborating Centre on Reproductive Health An academic center within a school of public health supports best practices in the ‘3Bs’: breastfeeding, birth spacing and birthing practice, at the community, state, national and global levels, through: –Applied and translational research –Graduate education –Evidence-based service and advocacy Golden Bow logo and mission

Why Breastfeeding? The Heartbeat of Maternal/Infant Health Logo, Breastfeeding Division, IRH Oral Rehydration Growth and Development Immunization: Diarrhea/ Pneumonia/ Ear infections Maternal Health and Survival Nutrition Birth Spacing and Fertility Reduced Cancer and Chronic Disease Breastfeeding supports: Family Health

10/2010 Percent of U-5 Child Death Preventable By:

CBI Mission To create an enabling environment, at the community, state, national and global levels, in which every mother is supported to choose and to succeed in optimal infant and young child feeding and care, and every child will achieve his or her full potential through this best start on life. Comprehensive approach Socio-ecological frame Intergenerational reproductive health frame

T 0 T 1 T 2 T 3 T 4 T 5 Relative Importance of Influence Pre-&Pregnancy Wks 1-2 Wks 6-8 Mo. 4-6 Mo >1yr Family, Workplace and Societal pressures Maternal Concerns About Breastfeeding Addressing Potential Obstacles and Providing Support for Breastfeeding by Time Period on the Reproductive Health Continuum Obstetric staff Pediatric Staff Maternity Staff

What are the Ten Steps and BFHI? The Ten Steps, developed in the late ‘80s, are the maternity care practices that serve as the basis for BFHI credentialing The WHO/UNICEF Baby-friendly Hospital Initiative: following the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding, 1 August 1990 The Declaration called on “all governments by the year 1995… to ensure that every facility providing maternity services fully practises all ten of the Ten Steps to Successful Breastfeeding” Baby-friendly or BFHI is the registered mark for the process by which governments implement, assign coordination, assess and monitor this activity.

The TEN STEPS to Successful Breastfeeding 1. Written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within one half-hour of birth. 5. Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants. 6. Give newborn infants no food or drink other than breastmilk, unless medically indicated. 7. Practice rooming in - that is, allow mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. 10.Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Background and Purpose Study of the Ten Steps Breastfeeding #1 intervention globally for child survival Estimates for US: Savings of billions of dollars, and hundreds of lives Breastfeeding support in hospitals is a major determinant of breastfeeding success. The “Ten Steps for Breastfeeding in the Maternity Setting” are the standard of best practice Generally ‘dose response’ Little in the literature exploring the impact of individual Steps to allow for prioritization by health system planners Purpose: to assess which step(s) may have most impact

Methods CDC Maternity Practices in Infant Nutrition and Care (mPINC) survey of hospitals across the US mPINC subscale scores for each set of practices reflective of each step were included in a forward stepwise regression analysis for association with state breastfeeding rates Statistical Analysis Software (SAS)

Results: State mPINC and State BF rates BFing Outcome NAssociated MPINC Scale Sig of variable F Value Sig of model INITIATION50Rooming-in<0.0001*23.11<0.0001* EBF AT 3 M51Rooming-in LD Skin-to-Skin Post discharge <0.0001* ** EBF AT 6 M51Rooming-in LD Skin-to-Skin Post discharge <0.0001* ** * Significant at the p< level ** Significant at the p<0.001 level

Findings and Discussion Rooming-in –significantly associated with the 3 outcome variables studied: initiation, exclusive breastfeeding (3 months) and exclusive breastfeeding (6 months). Postpartum skin-to-skin and post-discharge support planning –contributed to the model at 3 and 6 months, but did not independently achieve significant association. Discussion: –Limitations –Recommendation: May help to prioritize Steps 4 (immediate skin-to-skin), 7 (rooming-in) and 10 (post- discharge.

Conclusions: 1. The practice of rooming-in is strongly associated with statewide breastfeeding initiation, continuation and exclusivity. 2. Further exploration is needed to assess whether it is causative, a proxy for other practices, or a result of preexisting high level of interest in breastfeeding Thank you

For more information: Carolina Global Breastfeeding Institute (CGBI) Department of Maternal and Child Health Gillings School of Global Public Health, CB#7445 The University of North Carolina at Chapel Hill Chapel Hill, NC Tel: Fax: (associated blogspot - breastfeeding.blogspot.com) "It is kindness…selflessness…courage… but also a parent’s willingness to nurture a child that finally decides our fate” President Barack Obama, January 20, 2009

Global: –ABM –HMBANA –WABA –WHO/UNICEF –University-to-University collaborations Service State level: –NC State efforts –Hospitals –County health departments –Professional organizations –Child care –Community organizations National: –USBC –AHRQ –DHHS/OWH –CDC –USDA/FNS –IOM