Promoting maternal-child health by increasing breastfeeding rates: a National Canadian Baby-Friendly Initiative Quality Improvement Collaborative Project

Problem

Breastfeeding is a globally recognised indicator of maternal-child health and supporter of population health. Despite well-recognised benefits for breastfeeding persons and children, there are disparities in breastfeeding outcomes in Canada. While 91.1% of families initiate breastfeeding at birth (demonstrating intentions to breastfeed), only 34.5% of the 385 777 births in Canada met global recommendations of exclusively breastfeeding to 6 months of age in 2017–2018.1 The Baby-Friendly Initiative (BFI) is a WHO/UNICEF best-practice initiative that has demonstrated benefits in improving breastfeeding initiation, exclusivity and duration. Organisations can obtain ‘Baby-Friendly’ designation by complying with key steps that have been shown to promote quality person-centred and family centred maternal-child care. Baby-Friendly organisations provide evidence-based and integrated care to all families, regardless of their infant feeding decisions.

In Canada, the Breastfeeding Committee for Canada (BCC) is the national leader for BFI designation (in all provinces and territories except for Quebec) and is a key partner dedicated to the protection, promotion and support of breastfeeding. While there is momentum towards BFI implementation in Canada, many organisations struggle to implement sustained change and <10% of Canadian hospitals providing birthing care have BFI designation.

Recognising the need for increased BFI implementation, the BCC received a project innovation strategy grant (2019–2023) from the Public Health Agency of Canada (PHAC) to support the scale-up of BFI across the country. The core deliverable of this project was to implement a National BFI Quality Improvement Collaborative Project (BFI Project), with the aim of increasing the number of hospitals that moved towards BFI designation by 31 December 2023.

Background

The short-term and long-term health promoting benefits of breastfeeding are well established. Evidence from a meta-review of 22 systematic reviews and meta-analyses demonstrated that breastfeeding is associated with a reduction in sudden infant death, necrotising enterocolitis, otitis media and hospital admissions for diarrhoea and respiratory infections.2 Longer periods of breastfeeding are associated with reduction in the odds of overweight and obesity, incidence of type 2 diabetes and may be protective against type 1 diabetes.2–4 Breastfeeding is consistently associated with higher intelligence testing performance, with a pooled increase of 3.44 IQ points (95% CI 2.3 to 4.6) across 16 observational studies.2 5 Breastfeeding has long-term benefits for the mother/birth parent, including support of birth spacing,6 reduction in incidence of breast7 and ovarian cancer2 and reduced odds type 2 diabetes.2 8

Breastfeeding is an environmentally and economically responsible form of infant nutrition that promotes food sovereignty in Indigenous communities9 and household and community food security.10 11 Lack of access to clean water, which disproportionately impacts Indigenous communities,12 impacts safety of formula preparation. Increases in breastfeeding translate to economic gain and cost savings for the healthcare system. A 10% increase in exclusive breastfeeding to 6 months of age or continued breastfeeding to 2 years predicts a US$312 million annual reduction in treatment costs for childhood disorders in the USA.13 An economic return of US$35 for every US$1 invested in breastfeeding has been identified.14

There are global gaps in supportive environments for breastfeeding and associated outcomes. Intersections of the social determinants of health influence breastfeeding outcomes, with breastfeeding rates being lower in populations with lower levels of education and income, younger age and in racialized populations.15 Breastfeeding rates also vary based on region, with data from the 2022 ‘Canada’s Breastfeeding Progress Report’ highlighting that breastfeeding initiation ranged from as high as 96.4% in British Columbia to as low as 71.9% in Newfoundland and Labrador.1

The BFI is a WHO/UNICEF evidence-based practice initiative. It includes the Ten Steps to Successful Breastfeeding, which aim to optimise breastfeeding through enhanced knowledge, support and mother/birth parent-infant contact. Organisations can obtain ‘Baby-Friendly’ designation through successful implementation of the Ten Steps and by complying with the International Code of Marketing of Breastmilk Substitutes (The Code). After facilities self-assess that they are meeting the BCC BFI Implementation Guideline standards,16 they can enter into the official designation process with the BCC.17 This designation process involves documentation review and site visits with BFI assessors to evaluate the degree to which the facility meets all criteria outlined in the BFI Implementation Guideline.16

Adoption of the BFI is associated with increased rates of breastfeeding initiation and exclusivity across diverse clinical and cultural contexts.18–20 Implementation of the BFI is a complex change process requiring multilevel commitment and engagement across governments and health systems. A systematic evidence synthesis examining the barriers and facilitators to BFI demonstrate that BFI implementation is challenged by lack of health systems and government support, poor health service integration and communication, infant feeding norms and the powerful influence of the infant formula industry, inadequate healthcare provider education and socio-economic disparity.21

There is promising evidence for continuous quality improvement strategies increasing BFI implementation and designation. A Centers for Disease Control and Prevention-funded national quality improvement program across 90 facilities in the USA demonstrated rapid transformative changes to achieve Baby-Friendly designation in 80% of participating sites and an increase in exclusive breastfeeding rates from 39% to 61% at hospital discharge.22 However, there are significant gaps in education and leadership support for robust implementation of continuous quality improvement strategies in maternal-child care contexts in Canada.

In this BFI Project, we implemented continuous quality improvement approaches that have been successful in supporting the BFI. We incorporated partner-led adaptations of previously successful strategies to ensure relevance and impact in the Canadian context. The primary aim of the BFI Project was to increase the number of BFI designated hospitals in Canada from 21 to 26 by 31 December 2023. Secondary aims of the BFI Project were to engage 25 hospital teams and increase the following by 31 December 2023:

1. Number of hospitals that fulfilled the Ten Steps to Successful Breastfeeding.

2. Number of births that occurred in a Baby-Friendly hospital.

3. Breastfeeding exclusivity rate during hospital stay.

Measurement

Participating hospital teams were required to complete prework activities prior to the first quality improvement workshop in September 2019. This prework took place over 3 months (June—September 2019) and involved (a) attending a welcome call, (b) developing an individualised aim statement aligned with the BFI Project aim and driver diagram (online supplemental figure 2), (c) completing a self-assessment survey about the facility’s progress towards achieving the BFI Ten Steps, (d) attending webinars on measurement, data collection and quality improvement basics, (e) registering and developing a story board for the first workshop and (f) forming interprofessional improvement teams within their hospitals including parent partners.

Baseline measurement of key outcomes took place from October 2019 to December 2019 (table 1). During this time, facilities completed monthly chart audits based on the BCC BFI Implementation Guidelines,16 updated their patient chart documentation tools to ensure indicator data were collected and developed proficiency in using the data collection tools. The following indicators were collected in the chart audits: prenatal education; skin-to-skin contact following vaginal and caesarean birth; assistance with breastfeeding; rooming-in and separation of birthing parent and infant; breastfeeding initiation or any breastfeeding in hospital; breastfeeding exclusivity at discharge; breastfeeding supplementation for medical or non-medical reasons at discharge; formula feeding at discharge and education about community supports. Patient/birthing parent and healthcare provider surveys were pilot tested in two hospital facilities and feedback from parent partners was obtained. The surveys were administered three times to track experiences of Baby-Friendly care over time and to triangulate the results from the chart audit. All participating teams were required to collect and report on these data. Run chart reports including individual team’s data compared with the BFI Project aggregate data were generated by a QI consultant and shared back with teams monthly. All participating hospital facilities completed a yearly self-assessment measure based on the BCC BFI Implementation Guidelines.16

Design

Strategy

Three, 10-month action periods were used over the 30 months of the BFI Project (period 1: June 2019–March 2020; period 2: April 2020–January 2021; period 3: February 2021–November 2021) for all hospital teams. During the action periods, all participating teams used the IHI Breakthrough Series23 to guide PDSA QI cycles. While the action period timing and duration was the same for all hospital teams, each of the 25 participating hospital teams set unique cycle priorities based on their local context. Teams were supported to engage with families and clinical or administrative staff to develop priorities relevant to the local context based on each team’s unique BFI self-assessment, chart audit data and patient/birthing parent surveys. Teams met regularly through monthly webinars, learning workshops and action period calls to report on their PDSA cycles and share successes and challenges with other teams. Some examples of successful PDSA cycles that tested change ideas included: (1) use of transfer tools to support uninterrupted skin-to-skin contact during transfer from the operating room table to recovery area and obstetrical unit; (2) a new documentation tool to track rooming-in (tracking when separation of mother/birth parent and baby occurred); (3) education on documenting formula supplementation and (4) use of a stamp on the patient chart to trigger documenting breastfeeding support within 6 hours of birth.

Teams reviewed their progress, their monthly chart audits and run chart reports. Additional PDSA cycles were implemented based on learning from their previous cycles. Based on the feedback from participating teams, additional workshops and collaborative sharing of ideas and resources focused on these areas. For example, several workshops focused on skin-to-skin at birth, how to engage physicians in the needed changes, and reporting back on progress. Other examples included workshops on prenatal education, engaging parent partners in change and supporting leaders to conduct leadership rounds with patients and staff to better understand successes and areas for improvement.

Results

Chart audit data

Every month, each team audited 30 charts for mother/birth parent-baby dyads cared for on their postpartum unit, and, where applicable, 10 charts from infants admitted to the neonatal intensive care unit (NICU). Baseline chart audit data were collected over 3 months, from October to December 2019. Final results data were collected from all participating facilities from June to December 2021. Average baseline and results data across all participating organisations, along with target BFI implementation indicators are presented in table 1. Target values represent the target percentage of patients for whom the BFI indicators were supported, which are the required targets for BFI designation as outlined in the BCC BFI Implementation Guidelines.16

When examining trends in the BFI indicators over time, breastfeeding initiation rates remained high (above 80%) and stable for all teams (figure 1A). Breastfeeding exclusivity rates remained stable over time; however, they did not meet the target rate at any time for non-NICU (figure 1B) and NICU families (figure 1C). Skin-to-skin indicators all improved over the duration of the BFI Project, with rates of immediate (within 5 min of birth) and sustained (>1 hour) skin-to-skin following vaginal birth hitting the target (>80%, figure 2A). While rates of immediate and sustained skin-to-skin did not hit targets for caesarean births, there was consistent improvement from baseline (figure 2B).

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Figure 1

Breastfeeding sentinel indicators for the National BFI Quality Improvement Collaborative Project. (A) Breastfeeding initiation rates for entire BFI Collaborative. (B) Exclusive breastfeeding rates for entire BFI Collaborative. (C) Exclusive breastfeeding rates for dyads admitted to the NICU. BFI aggregate represents the percentage of sites that met targets in their reported chart audit data. Aggregate n represents the total number of sites that provided chart audit data at each time point.

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Figure 2

Skin-to-skin rates after birth. (A) Rates of placing infants skin-to-skin after vaginal birth. Blue line: Immediate skin-to-skin (within 5 minutes of birth) Purple line: Sustained skin-to-skin (1 hour or more of uninterrupted skin-to-skin). (B) Rates of placing infants skin-to-skin after Caesarean birth. Blue line: Immediate skin-to-skin (within 5 minutes of birth) Purple line: Sustained skin-to-skin (1 hour or more of uninterrupted skin-to-skin). Aggregate n represents the total number of sites that provided chart audit data at each time point. Aggregate values reported for rates of skin-to-skin within 5 minutes (blue line) and rates of skin-to-skin for 1 hour or more (purple line) represents the percentage of sites that met targets in their reported chart audit data.

Similar positive trends were observed for BFI care indicators, with the following indicators reaching targets: documented assistance and support with breastfeeding within 6 hours of birth for non-NICU (figure 3A) and NICU families (figure 3B), and rooming-in (figure 3C). Aggregate targets were not met for prenatal education. However, there was an upward trend over time (figure 3D), with five facilities reporting meeting prenatal education target values. One site demonstrated stable prenatal education that met target values over time (figure 3D). The remaining four facilities demonstrated progressive improvement over time.

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Figure 3

Baby-Friendly care indicators. (A) Rates of documented assistance and support of breastfeeding within 6 hours of birth. (B) Rates of documented assistance and support with breastfeeding among dyads admitted to the NICU. (C) Rates of rooming-in during the birth hospital stay. (D) Rates where prenatal education was documented for dyad. Aggregate represents the percentage of sites that met targets in their reported chart audit data. Aggregate n represents the total number of sites that provided chart audit data at each time point. In figure 3D, site T represents one facility in the BFI Project that demonstrated stable documented prenatal education over the duration of the Project. In figure 3D, AG represents aggregate and AG n represents aggregate n.

Lessons and limitations

The aim of this BFI Project was to increase the number of BFI designated hospitals in Canada by implementing novel continuous quality improvement approaches at 25 Canadian hospitals. Three facilities achieved Baby-Friendly designation during the time frame of the BFI Project and six facilities have started the official process towards attaining designation with the BCC.

Sustainability and future directions

To extend and sustain the work of this BFI Project, the BCC has established a BFI Coach Mentor Program.26 Funding support has been extended into 2024. Coach mentors and parent partners, many of whom participated in the BFI Project, have been contracted to support additional hospitals as well as community health services facilities (such as public health units) in Canada to implement the BFI. Broadening programming to community health services (which were not included in the original BFI Project) will allow focus on upstream approaches to promote breastfeeding throughout the continuum of the perinatal period. Coach Mentors will assist facilities in areas such as data collection, reporting and quality improvement strategies.26 There are currently 47 hospitals and public health units enrolled in the BFI Coach Mentor Program. Continued data collection and measurement for observation of (1) the sustainability of BFI Project and Coach Mentor Program; (2) how sentinel indicators of breastfeeding initiation and duration respond to changes in BFI care practice indicators and (3) how many teams move forward to BFI designation is needed to fully understand the long-term impact of the BFI Project. The data collection tools and resources from the BFI Project have been updated and expanded to include community health services. Updated tools that have been shared on the BCC website (breastfeedingcanada.ca) include chart audit manuals, excel templates and patient/birthing parent survey templates. Additional tools for creating run chart reports are in development and will be posted on the BCC website to be available to facilities nationally. Future directions include continuing to partner and influence Accreditation Canada’s Omentum Program related to perinatal health and breastfeeding. Focus on NICU settings as well as Indigenous populations are needed areas for additional BFI support.

Conclusion

This BFI Project demonstrated that hospitals could successfully implement Baby-Friendly practice in various Canadian settings. As of December 2023, three hospitals in the BFI Project attained BFI designation and six have started the official process towards obtaining designation with the BCC. Indicators collected as part of this work demonstrate that delivery of Baby-Friendly care improved in the participating facilities and teams are continuing to progress towards BFI designation. Critical success factors of BFI implementation included use of the IHI Breakthrough Series Model, quality improvement strategies, the multisite nature of the project, parent partner engagement, representation of hospital sites across Canada, committed leadership and funding support and capacity in data collection, analysis and reporting. Competing organisational priorities and variations in leadership and human resources during the COVID-19 pandemic were barriers. Implementation of a BFI Coach Mentor Program to sustain and scale up BFI implementation in hospitals and community health services across Canada is ongoing to enable continued progress and impact on breastfeeding and maternal-child health.