Keeping Women Breastfeeding

Laurie Scudder, DNP, NP


April 25, 2013

Evaluation of an Office Protocol to Increase Exclusivity of Breastfeeding

Corriveau SK, Drake EE, Kellams AL, Rovnyak VG
Pediatrics. 2013;131:1-9

Study Summary

Increasing the number of women who exclusively breastfeed their infants is a public health imperative, endorsed by organizations such as the World Health Organization (WHO), the American Academy of Pediatrics (AAP), and the US Surgeon General. The Centers for Disease Control and Prevention's annual Breastfeeding Report Card finds that growing numbers of women are initiating breastfeeding in the early postpartum period, although exclusivity and duration of breastfeeding decline rapidly thereafter. The Academy of Breastfeeding Medicine (ABM) has published a clinical protocol[1] based on the WHO Baby-Friendly Hospital Initiative that provides guidance on the incorporation of breastfeeding support in primary care settings to encourage women to exclusively breastfeed their infants for the first 6 months of life.

Methods. This study was conducted in a large primary care practice with 2 offices, one suburban and the other rural. A retrospective before-and-after design was used. Data were collected from 2 groups of patients: a preintervention group that included infants presenting for routine health maintenance visits before the initiation of the ABM protocol, and a second group of infants who were seen after the protocol was in place. Demographic and feeding data were collected from electronic health records (EHRs) from the hospital stay, the newborn visit, and the 2-, 4-, and 6-month health maintenance visits. Study infants were healthy, ≥ 37 weeks gestation, singleton births, entered the pediatric practice in the first week of life, and remained with the practice through the first 6 months of life. Excluded were infants with congenital defects, preterm infants, multiple births, infants not residing with their birth mothers, those whose mothers had known contraindications to breastfeeding, and those with missing visits or EHR data. The protocol included the following:

Implementation of an AAP/WHO-approved breastfeeding curriculum for staff training;

On-site lactation support by International Board Certified Lactation Consultants for all nursing mothers;

Community outreach (weekly drop-in support groups for mothers, and prenatal visits that exposed women to a healthcare setting that supported breastfeeding); and

Use of an EHR template that prompted clinicians to identify and document indications for lactation support such as excessive infant weight loss, inadequate stool output, or maternal breastfeeding concerns.

Findings. Data from 376 preintervention and 381 postintervention mother-infant dyads were collected. The sample size was large enough to have 93% power to detect a pre-post increase in breastfeeding rates of 10%. There were no significant differences between the groups with respect to infant sex, birth weight, type of delivery, maternal age, or type of insurance. There was a statistically significant increase of at least 10% in the rates of exclusive breastfeeding in the postintervention group at all time points. Although rates were also higher in the postintervention group for any breastfeeding at all time points, that difference was statistically significant only at the 1-week time point. The researchers used multiple regression analyses to identify other factors that might affect breastfeeding. Type of insurance was found to be highly significant. The estimated odds for any or exclusive breastfeeding in women receiving Medicaid was only 28%-47% of the odds for women with private insurance. Infant birth weight was also found to be an important indicator, with the odds of exclusive breastfeeding increasing in a dose-response fashion with each additional 100 g of infant birth weight. Although women who delivered by cesarean section were less likely to exclusively breastfeed while in the hospital, they were not less likely to exclusively breastfeed at later time points. Maternal age and parity were not significant predictors of breastfeeding at any point in time.