1. Breastfeeding and Environmental Change: A Focus on Maternity Care Practices The Massachusetts Experience Rachel Colchamiro, MPH, RD, LDN, CLC State Breastfeeding Coordinator Massachusetts Department of Public Health Nutrition Division

2. Breastfeeding in Massachusetts (2005 data) 79% breastfeeding initiation rate 45% breastfeeding at 6 months; 25% breastfeeding at 12 months 43% exclusively breastfeeding at 3 months; 17% exclusive at 6 months

3. Why Focus on Maternity Care? Time-sensitive nature of breastfeeding success Evidence of positive impact of “breastfeeding- friendly” hospital practices Significant impact of supplementation on later breastfeeding duration and exclusivity

4. It’s All About Timing…

5. Perinatal Hospital Licensure Regulations Purpose: Improve quality of care for all women giving birth in Massachusetts and their newborn infants Improve perinatal outcomes – maternal and infant Better serve Massachusetts families More efficiently provide services to mothers and newborns in Massachusetts

6. Need for Revision Regulations initially promulgated in mid 1970’s and revised in the late 1980’s Part of a multi-faceted strategy to reduce mortality Health care delivery changes and technology have changed environment resulting in need to update existing regulations Research informs best practices to promote positive health outcomes

7. Massachusetts Breastfeeding Coalition Rejuvenated in 2000 by a consumer/physician Made up of advocates, health professionals, hospitals and health departments, community organizations, consumers and parents Includes many prominent individuals in breastfeeding arena Membership eager and willing to work for change Excellent website and history of social marketing campaigns

8. Our Hopes and Dreams Increase breastfeeding duration and exclusivity Mandate a level of lactation support in the maternity setting Improve initiation of breastfeeding by keeping dyad together Regulate documentation related to feeding Improve staff knowledge and ability Eliminate marketing practices that negatively affect breastfeeding

9. Process - Revision to Regulations Began January, 2004 Joint process between two bureaus – Center for Quality Assurance and Control and Center for Community Health Development of Advisory Committee and Sub-Committees- -Massachusetts Breastfeeding Coalition leaders active on committees Lengthy review and approval process including: Public Health Council Public comment hearings Department of Public Health review of comments and revisions Review by governor and his cabinet

10. Our Successes: Key Changes to Regulations Promoting Breastfeeding Availability of a Lactation Consultant Strengthening of patient care policies related to lactation Documentation of infant feeding care & progress Discharge planning Staff education/training in lactation

11. Significant Sections Related to Breastfeeding Each hospital, at a minimum, must provide each mother advanced lactation support with consultation from an International Board Certified Lactation Consultant (IBCLC) or an individual with equivalent training and experience

12. Patient care policies must include: Encouragement of breastfeeding as soon after birth as baby is interested Encouragement of skin-to-skin care Safe storage and handling of infant feedings (labeling and identification) Significant Sections Related to Breastfeeding

13. Maternal/newborn record includes infant feeding method, plan of care/progress and documentation of lactation care/services provided Newborn record must include documentation of at least 2 successful feedings and discharge instruction sheet related to feeding plan, referrals an follow-up care signed by infant’s practitioner Significant Sections Related to Breastfeeding

14. Each hospital must provide provision of resources to assist mother/family after discharge including community-based lactation resources and availability of breast pumps All nursing staff shall receive orientation and periodic in-service education related to initiation and support of lactation Significant Sections Related to Breastfeeding

15. What about the bags? Original language Sample formula and/or formula equipment distributed to breastfeeding mothers only when an individual physician order is written or on the request of the mother

16. Coalition Tactics Press Online petition Looking at the issue from another angle Ad placement Demonstration at State House Buy-in from major teaching hospital

19. The Loss…and the Wins Language regarding sample formula in regulations unchanged Successes…14 birthing hospitals in Massachusetts no longer distribute bags Creation of Ban the Bags campaign Impact nationwide

20. Challenges of Making Change with Perinatal Regulations Trickle-down of knowledge Staffing and funding for reviews Regulations vs. guidelines Issues with evaluation

21. Power of Coalitions Advocate power State agency power Researcher power Health professional power

22. Future Steps for Massachusetts Birth certificate Peer counselors in hospitals Legislation Follow-up to regulations