Abstract
Background:
The Baby-Friendly Hospital Initiative (BFHI) has a positive effect on breastfeeding in maternity wards; however, few studies have examined to what degree it affects care in neonatal intensive care units (NICUs). Recently, the BFHI has been adapted to the NICUs (Neo-BFHI).
Objective:
This study aimed to compare breastfeeding support in Spanish NICUs in hospitals with BFHI accreditation or in the process of being accredited (group 1) with NICUs in hospitals that have not yet begun this initiative (group 2).
Methods:
A validated questionnaire on breastfeeding support was distributed to level II and III NICUs in Spanish public hospitals. A univariate analysis and an analysis adjusted for the number of beds in NICUs were conducted. The results of the analysis of 36 breastfeeding support measures are presented in accordance with the Ten Steps to Successful Breastfeeding adapted to NICUs.
Results:
Of the 141 participating NICUs, 129 (91%) responded to the questionnaire: 38 NICUs from group 1 and 91 NICUs from group 2. Group 1 had implemented a higher number of breastfeeding support measures than group 2. There were significant differences in 18 measures related to steps 2, 4, 5, 7, and 8 of the Neo-BFHI. In addition, a comparison of NICUs in hospitals with full accreditation (7 of 129) with those in group 2 revealed significant differences in 7 measures pertaining to steps 2, 5, 8, and 9.
Conclusion:
The Spanish NICUs in hospitals with BFHI accreditation or in the process of being accredited have better implementation of practices to promote and support breastfeeding.
Keywords
Well Established
Successful breastfeeding in neonatal intensive care units is complex. Mothers of preterm and sick infants often encounter more difficulties with breastfeeding than mothers of healthy term newborns. Policies promoting breastfeeding in neonatal units vary between countries.
Newly Expressed
Baby-Friendly hospitals have better implementation of breastfeeding support measures in neonatal intensive care units. The benefits of Baby-Friendly accreditation of maternity wards extend beyond the specific actions that it promotes and assesses.
Background
The World Health Organization (WHO); the American Academy of Pediatrics; the European Society for Paediatric Gastroenterology, Hepatology and Nutrition; and the Spanish Pediatrics Association recommend that sick and preterm newborns be fed breast milk on the basis that breast milk substitutes are associated with an increase in both short- and long-term adverse outcomes.1-4 Despite this recommendation, breastfeeding rates in neonatal intensive care units (NICUs) vary greatly; hence, preterm babies are less likely to initiate breastfeeding and are breastfed for less time than term infants.5-7 In an effort to reverse this situation, support and promotion of breastfeeding have become part of the day-to-day work in NICUs. Effective measures have been defined for promoting breastfeeding in NICUs8-9; however, there is a lack of standardization in the manner in which policies are applied. 10
In 1989, the WHO and UNICEF designed the Baby-Friendly Hospital Initiative (BFHI), with 10 steps for protecting, promoting, and supporting breastfeeding in maternity wards 11 ; several studies have since shown that the application of this strategy increases breastfeeding rates in maternity services.12-13 In 2009, the WHO and UNICEF identified the need to extend the BFHI program to the neonatal setting but failed to specify the standards to be followed. 14 In response to their suggestion, a team of breastfeeding experts was created. The Ten Steps to Successful Breastfeeding (Ten Steps) of the BFHI were adapted to the needs of NICUs (Neo-BFHI) (Table 1), and Three Guiding Principles were added, specifying that staff attitudes toward the mother must focus on the individual mother and her situation; the facility must provide family-centered care, supported by the environment; and the health care system must ensure continuity of care from pregnancy to after the infant’s discharge.15-17 Neo-BFHI confidential tools have been developed and are available to BFHI country coordinators. To date, Spain has no BFHI accreditation for NICUs.
Abbreviation: Neo-BFHI, Baby-Friendly Hospital Initiative for Neonatal Wards.
Previous studies18-21 indicated that BFHI accreditation of maternity services increases breastfeeding rates at discharge from the NICU. However, no information exists regarding which breastfeeding promotion measures in the NICUs improve with the BFHI accreditation of the maternity wards. Therefore, following the protocol outlined by the Ten Steps of Neo-BFHI, our study aimed to compare the breastfeeding support measures in the NICUs of Spanish hospitals with BFHI accreditation or in the process of being accredited with those NICUs that have not yet begun the accreditation process.
Methods
Design
From November 2013 to March 2014, a survey on breastfeeding support measures was distributed to level II and level III NICUs in Spanish public hospitals. 22 Neonatal units were identified based on an official document provided by the Spanish Ministry of Health. In Spain, 79% of births take place in public hospitals.
Study Protocol
The NICUs that accepted to participate in the project were previously informed about the study protocol. The encoded survey was then sent by email to the doctor in charge of each unit who could personally complete the survey with his or her team or delegate to another doctor in the unit. Email reminders were sent at 15-, 30-, and 60-day intervals. All data were treated confidentially.
Since 2011, BFHI accreditation of the maternity wards in Spain, as with other countries,23,24 has been carried out in 4 stages (Figure 1), with a phased implementation of the Ten Steps.25,26 In 2015, the requirements for each stage were modified. 25
The BFHI-Spain Pathway, a 4-Stage System of Accreditation of Hospitals. 26
Participating NICUs were informed that the survey was related to breastfeeding support measures in Spanish NICUs; however, they were not initially told that the analysis of the results would be performed based on the BFHI accreditation process. This information was provided later.
Given the nature of the survey, it was shown to the 12 de Octubre Hospital Ethics Committee, but ethics approval was not necessary as the Ethics Committee gave the survey a waiver. All aspects of this study were performed in accordance with the ethical standards laid out in the 1964 Declaration of Helsinki.
Survey
A questionnaire designed in Denmark in 2012 was used to prepare the survey 10 after first requesting permission from the main author.
A team of 5 doctors and a neonatal nurse, 4 of whom were International Board Certified Lactation Consultants, was created. Of the 56 questions in the Danish questionnaire, 51 were selected; the remaining 5 were rejected due to lack of relevance to the Spanish context. Following a review of the literature, a first draft of the questionnaire with 74 questions was drawn up and a new group of 12 health care professionals (doctors and nurses) was then formed to analyze and complete the questionnaire. The aim was to confirm that it covered all relevant aspects of support for breastfeeding in NICUs and that the questions were clearly formulated. As a result of this process, 3 questions were added and 2 that led to confusion were removed. A consensus was finally reached on a definitive survey with 75 questions (Appendix 1) divided into the following sections: characteristics of the unit (10 questions), family support measures (11 questions), written protocols and practices for breastfeeding (41 questions), and Kangaroo Mother Care (KMC) (13 questions). There was 1 open question; the rest were closed or multiple choice. In general, only 1 option could be chosen, although some questions allowed for multiple responses.
Data Analysis
In this study, we analyzed 36 breastfeeding support measures related to the Ten Steps of the Neo-BFHI: 1 characteristic of the unit, 4 family support measures, 28 breastfeeding protocols and practices, and 3 KMC practices.16,17 The results were grouped in accordance with these Ten Steps.
Two comparisons were made. First, NICUs in hospitals that had or were in the process of obtaining BFHI accreditation (group 1) were compared with those that had not started the accreditation process (group 2). Second, the breastfeeding support measures in the NICUs of hospitals with full accreditation (BFHI group) were compared with those in group 2.
Continuous variables are presented with the means and standard deviations (SDs) and the categorical variables with absolute and relative frequencies. The statistical significance of the comparison of proportions between study groups was determined using the chi-square test or Fisher exact test for contingency tables if more than 25% of the expected values were less than 5. Comparisons between groups for the number of intensive care beds were performed using the Wilcoxon–Mann–Whitney test. The relationship between group 1 and group 2 hospitals and the different breastfeeding support measures were adjusted for the number of intensive care beds using logistic regression. A P value of less than .05 was considered statistically significant. The final regression model provided odds ratios with 95% confidence intervals.
Results
Neonatal Unit Characteristics
Of the 141 participating NICUs, 129 (91%) responded to the questionnaire; 76 level III and 53 level II. With respect to BFHI accreditation, 16.3% (21 of 129) were at stage 1D, 7% (9 of 129) were at stage 2D, 0.8% (1 of 129) were at stage 3D, and 5.4% (7 of 129) had full accreditation.
Of the 12 units that did not respond, 1 was level III and the rest were level II. Only 1 of the nonresponding units had started the BFHI accreditation process.
Group 1 was made up of 38 units in hospitals with maternity wards already accredited or in the process of obtaining BFHI accreditation. Group 2 comprised 91 units in hospitals with maternity services that had not started the accreditation process.
Comparison between Group 1 NICUs and Group 2 NICUs
The mean number of intensive care beds in group 1 was 4.37 ± 5.32 compared with 6.7 ± 6.15 in group 2 (P = .01). Among the units, 53% (69 of 129) reported recording breastfeeding rates at discharge; 73% in group 1 versus 45% in group 2 (P = .003).
Group 1 NICUs reported having implemented a greater number of measures to support breastfeeding than group 2. There were significant differences in 18 measures related to steps 2, 4, 5, 7, and 8 of the Neo-BFHI. These differences were consistent in all but 1 measurement after correcting for the number of intensive care beds (Table 2).
Comparison of the Breastfeeding-Support Measures in NICUs in Group 1 and Group 2 Hospitals. a
Abbreviations: BF, breastfeeding; CI, confidence interval; CPAP, continuous positive airway pressure; Neo-BFHI, Baby-Friendly Hospital Initiative for Neonatal Wards; NICU, neonatal intensive care unit; OR, odds ratio.
N = 129. Included are a univariate analysis (P value) and an analysis adjusted for the number of beds in NICUs (OR).
Some units did not respond to specific questions; therefore, total n is different for these questions.
More units in group 1 versus group 2 had implemented systematic breastfeeding training for staff (73% vs 43%); early (90% vs 61%), prolonged (97% vs 75%), and postdischarge KMC (94% vs 77%); pumping milk in the first 6 hours postpartum (73% vs 55%); combining breastfeeding with nasal continuous positive airway pressure (CPAP) (65% vs 33%); and demand breastfeeding (63% vs 27%) or semi-demand breastfeeding during the transition from tube to breast (57% vs 32%).
Comparison between BFHI Group NICUs and Group 2 NICUs
The implementation of measures to support breastfeeding was better in the group of hospitals with full accreditation (BFHI group) compared with group 2. There were significant differences in 7 measures analyzed related to steps 2, 4, 8, and 9 of the Neo-BFHI (Table 3).
Comparison of the Breastfeeding-Support Measures in NICUs in Hospitals with Accredited Maternity Services (BFHI Group) and Hospitals That Have Not Begun an Accreditation Process (Group 2).
Abbreviations: BF, breastfeeding; CPAP, continuous positive airway pressure; Neo-BFHI, Baby-Friendly Hospital Initiative for Neonatal Wards; NICU, neonatal intensive care unit.
Some units did not respond to specific questions; therefore, total n is different for these questions.
More units in the BFHI group versus those in group 2 had implemented systematic breastfeeding training for staff (100% vs 43%), demand breastfeeding (71% vs 27%), and a combination of breastfeeding with KMC (100% vs 45%) and nasal CPAP (100% vs 33%). Furthermore, it was evident that fewer units in the BFHI group use bottles before breastfeeding (28% vs 78%).
Discussion
Our study shows that NICUs in hospitals with BFHI accreditation or in the process of being accredited have more measures in place for protecting, promoting, and supporting breastfeeding than NICUs in hospitals that have not begun the accreditation process. The better implementation of best practices was observed in measures related to steps 2, 4, 5, 7, and 8 of the Neo-BFHI. These results were consistent in all but 1 measurement after correcting for the number of intensive care beds. The differences in measures to support breastfeeding, therefore, do not depend on the degree of complexity of the NICUs and appear to be associated with the BFHI accreditation process. A separate analysis of NICUs in hospitals with full accreditation compared with NICUs in hospitals that had not begun the accreditation process revealed that significant differences persisted in 7 analyzed breastfeeding support measures despite the fact that only 7 hospitals were fully accredited.
To obtain BFHI accreditation of maternity wards in Spain, breastfeeding support practices in the NICU are assessed following the WHO/UNICEF criteria. These practices are part of step 4 (allow KMC in the NICU) and step 5 (show mothers how to breastfeed and how to maintain lactation even if separated from their infants). Our study shows that differences in practices extend beyond what is assessed in order for a maternity service to obtain BFHI accreditation; these differences are evident even when the service is going through the accreditation process.
Some individual centers18-21 previously reported an increase in breastfeeding rates at discharge from NICUs after BFHI accreditation of their maternity services. However, they did not specify which measures made the difference. Merewood et al 18 examined the factors that may have had an effect on this increase in the NICU and concluded that, of the Ten Steps in maternity services, steps 1, 2, 3, 5, 6, and 10 were decisive. Nevertheless, in a systematic review, Renfrew et al 9 recommended further research to evaluate the effect of BFHI accreditation of the maternity wards on NICUs.
In our study, no significant differences were found between the groups studied in step 1 of the Neo-BFHI (written breastfeeding policy); this step is not mandatory until stage 2D of the BFHI in Spain.25,26
For step 2 of the Neo-BFHI (train all staff to implement this policy), staff training had been implemented more extensively in group 1 than in group 2. Staff training carried out for accreditation of the maternity ward likely has a positive influence on the health care staff in the NICU; this training is 1 of the most effective measures for promoting breastfeeding in NICUs.8,9
In step 3 of the Neo-BFHI (inform hospitalized pregnant women at risk for preterm delivery or birth of a sick infant), no differences were found, and there has been little implementation of this measure.
With respect to step 4 of the Neo-BFHI (encourage early, continuous, and prolonged KMC), more units in group 1 than in group 2 practiced early KMC (during the first 24 hours after delivery or during the parents’ first visit to the unit), practiced it for longer (more than 2 hours for a stable incubator infant), and continued KMC after discharge (at home). This finding is important because KMC has been identified as 1 of the most effective measures for promoting breastfeeding in NICUs.8,9 As previously noted, the use of KMC in NICUs is assessed for maternity services accreditation; however, neither initiation time nor duration are taken into consideration.
Step 5 of the Neo-BFHI (show mothers how to initiate and maintain lactation and establish early breastfeeding) includes measures common to step 5 of the Ten Steps for maternity services. Likely for this reason, more units from group 1 recommend expressing milk within 6 hours of delivery and expressing more than 8 times per day. They also provide more written information and workshops for parents. However, step 5 of the Neo-BFHI also includes other aspects specific to NICUs, such as the early establishment of breastfeeding with the stability of the infant as the only criterion. In our study, a higher proportion of NICUs in hospitals with full accreditation (BFHI group) were recommending sucking at the breast with KMC and/or with nasal CPAP than NICUs in group 2. However, the difference was less striking when comparing units in group 1 with those in group 2.
Step 6 of the Neo-BFHI (give newborn infants no food or drink other than breast milk) recommends feeding with donor milk in the absence of mother’s breast milk. In our study, there was little use of donor milk (there are only 8 milk banks in Spain), and there were no significant differences between the different groups. For this reason, we assessed other parameters that reflect the degree of interest that each NICU had in the mother’s breast milk, such as the availability of freezers and written guidelines for handling breast milk. No differences were found between group 1 and group 2 in any of the parameters.
Step 7 of the Neo-BFHI (enable mothers and infants to remain together 24 hours a day) is difficult to comply with in Spain because very few units are structurally adapted for rooming-in. We therefore analyzed the policy on parent visits and other measures that favor their stay in the unit. Significant differences between groups 1 and 2 were found only in the measure allowing rooming-in prior to discharge.
In step 8 of the Neo-BFHI (encourage demand feeding or semi-demand feeding as a transitional strategy), group 1 showed significantly better implementation of measures allowing demand or semi-demand breastfeeding during the transition from tube to breast.
In step 9 of the Neo-BFHI (use alternatives to bottle feeding at least until breastfeeding is well established and use pacifiers and nipple shields only for justifiable reasons), no differences were found between groups 1 and 2 after correcting for the number of NICU beds. There were significant differences, however, when comparing units with full accreditation with group 2 (28% vs 78% used bottle-feeding before breastfeeding is established) suggesting that the accreditation process needs to be more advanced for this measure to be implemented.
Last, in step 10 of the Neo-BFHI (ensure access to support services after hospital discharge), we assessed only the contact between the NICUs and primary care services. There is very little implementation of this measure in either group.
The majority of measures analyzed are implemented more often in units in group 1 and the BFHI group versus group 2, although in some measures, significant differences were not detected, possibly due to the limited sample size.
Maastrup et al 10 conducted a similar survey in 19 Danish NICUs and also found that BFHI hospitals (N = 4) had more thoroughly implemented breastfeeding support measures; notably, the differences were not significant. However, our study detected significant differences, probably because our sample was substantially larger. Further studies are needed before these results can be generalized. When we compare the results of the 2 surveys, lower rates of implementation in Spain were found for measures such as the use of donor milk (84% in Denmark vs 20% in Spain), rooming-in during the final days prior to discharge (100% in Denmark vs 24% in Spain), and the recommendation for double breast pumps (89% in Denmark vs 20% in Spain). In Spain, the use of bottles before breastfeeding is more common than in Denmark (72% vs 11%). In both countries, the least implemented Neo-BFHI steps are 3 and 10.
The study also shows that BFHI accreditation of maternity wards, at least in the Spanish context, is not sufficient to ensure that most breastfeeding support measures are implemented in associated NICUs. Thus, additional measures are needed to ensure that preterm and sick newborns receive optimal care. Neo-BFHI accreditation would probably achieve better outcomes, but further studies are needed for confirmation.
The primary limitation of our study is that we cannot confirm better rates of breastfeeding in the NICUs of hospitals with or in the process of obtaining accreditation. Only 53% of the units studied recorded the type of feeding at discharge. In addition, the use of a questionnaire is in itself a limitation because practices should ideally be assessed on site. There may be a bias related to the use of a sole key informant, a doctor in charge of the unit. However, we believe that we were able to keep bias at a minimum because the NICUs did not know that the analysis of the results would be performed based on the BFHI accreditation process.
The results were adjusted for the number of intensive care beds as significant differences were found when group 1 and group 2 were compared (higher in group 2). Ideally, it would have been desirable to make the adjustment for the level of care of NICUs. Furthermore, in Spain, care levels in NICUs are not officially recognized in all regions and the authors had doubts regarding many of the care level designations reported in the survey. For this reason, data on the number of intensive care beds appear to be the most objective measure available in order to demonstrate, at least in part, the complexity of the unit.
The primary strength of our study is that it includes data from the vast majority of public NICUs in Spain and, after considering virtually all measures studied, concludes that the more favorable outcome leans toward group 1. These results may indicate that working according to the BFHI accreditation standards improves practices in these units.
Conclusion
Our study shows that there is an increase in the number of measures for protecting, promoting, and supporting breastfeeding implemented in the associated NICU when a maternity ward has obtained or is working toward obtaining BFHI accreditation. This fact is especially important when considering that, although preterm or sick newborns constitute 1 of the most vulnerable populations, they receive the lowest percentage of breastfeeding. In light of these results, the benefits of BFHI accreditation of maternity services extend beyond the specific actions it promotes and assesses. This is 1 more reason to encourage maternity wards to begin the BFHI accreditation process.
Footnotes
Appendix 1. Survey on Breastfeeding-Support Measures
Acknowledgements
The authors would like to thank all the Spanish neonatal units that participated in the survey. They would also like to thank Ragnhild Maastrup for providing the survey previously used in Denmark. They also thank SAMID Spanish Collaborative Network and Abraham Luis Pavón for supporting the study.
Declaration of Conflicting Interests
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The Hospital 12 de Octubre achieved BFHI accreditation in 2011. Drs Pallás-Alonso, Alonso-Díaz, Flores-Antón, and Alba-Romero currently represent the Spanish Baby-Friendly Hospital Initiative.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.