Feature

Reducing Health Care Disparities by Providing Incentives for Evidence-Based Practices around Breastfeeding

The Massachusetts Breastfeeding Coalition is working with breastfeeding advocates nationwide to formulate a proposal to encourage hospitals to adopt more evidence-based breastfeeding practices. The proposal and its rationale are discussed in a blog entry published in the Huffington Post by MBC chair Dr. Melissa Bartick. “If we’re serious about promoting breastfeeding in this country, there’s a whole lot more we can do,” says Bartick. Download a copy of the proposal or read it below, post a comment, and spread the word!

Background:

• The Surgeon General and the CDC recognize significant disparities in breastfeeding rates with lower income populations and African-American women breastfeeding at lower rates.
• Breastfeeding rates after hospital discharge fall well short of Healthy People 2010 Goals.¹, ²
• Fewer than 3%³ of US hospitals are  certified as Baby-Friendly, meaning they comply with a package of ten evidence-based practices outlined by WHO/UNICEF to promote breastfeeding (The Baby-Friendly Hospital Initiative).⁴
• Hospitals which adhere to the Baby-Friendly ten steps have been shown to have greater duration of breastfeeding and higher rates of exclusive breastfeeding.^5-9 The CDC has shown that most hospitals fall well short of optimal breastfeeding practices.¹⁰
• All major medical authorities recommend babies get no other food or drink than human milk for the first 6 months of life, with continued breastfeeding for at least the first 1-2 years of life.^11-16
• California has publicly reported “any” and “exclusive” breastfeeding rates for all hospitals, emphasizing the gap between the two rates, which has encouraged many hospitals to adopt evidence-based practices for newborn and breastfeeding care.
• The National Quality Forum is proposing measuring exclusive breastfeeding in the hospital as one of 15 quality metrics for perinatal care.
• Withholding 0.5% of a DRG for failure to meet specific breastfeeding objectives resulted in significant increases in breastfeeding in Northern Italy¹⁷ (no such program has ever been implemented in the US).

Public Health and Financial Impact:

• Increasing breastfeeding rates in the US will save money¹⁸ and lives.¹⁹
• Evidence-based best hospital practices have resulted in marked increases in exclusive breastfeeding in the hospital, even in Medicaid populations.
• Hospital rates of exclusive breastfeeding correspond with a hospital’s implementation of evidence-based best practices and thus likely predict longer breastfeeding duration.
• Exclusive breastfeeding for 3 months reduces health care costs for infants in the first year of life by up to $475, compared to non-breastfed infants.²⁰
• Early cessation of breastfeeding increases the risk of many costly or chronic diseases in offspring: obesity, diabetes (types 1 and 2), SIDS, and leukemia.²¹
• Early cessation of breastfeeding increases the risk of maternal breast cancer, ovarian cancer, and type 2 diabetes.²¹

Performance Incentive Proposal:

• Urge all states to publicly report their hospitals’ rates of breastfeeding initiation and the rates of supplementation for breastfed babies, and use this metric as a leading 
  pediatric/maternal quality indicator. Any/exclusive breastfeeding can be measured at one
  point in time at 24 to 96 hours of life, such as during routine genetic screening.
• Provide a monetary bonus for hospitals who maintain a supplementation rate of less than 15%, or who decrease their supplementation rates by at least 15 percentage points per year.
• Consider providing a monetary bonus for hospitals that have achieved designation as a Baby-Friendly Hospital(TM) after the objective evaluation of Baby-Friendly USA.
• Consider providing a monetary bonus for office providers who are compliant with the International Code of Marketing of Breast-milk Substitutes²² and publicly report them.

Proposed by

The Massachusetts Breastfeeding Coalition, in collaboration with:

• the United States Breastfeeding Committee;
• the Maternal and Child Health Section of the American Public Health Association:
• the National Alliance for Breastfeeding Advocacy;
• Baby Friendly USA;
• Merced County Breastfeeding Coalition (CA); and
• Bright Future Lactation Resource Centre (Dayton, OH.)

References

1. Shealy K, Li R, Benton-Davis S, Grummer-Strawn L. The CDC Guide to Breastfeeding Interventions. Atlanta: US Department of Health and Human Services, Center for Disease Control and Prevention; 2005.
2. US Department of Health and Human Services. HHS Blueprint for Action on Breastfeeding. Washington, DC: US Department of Health and Human Services, Office on Women’s Health; 2000.
3. US Baby-friendly hospitals and birth centers as of February 2008. 2008. (Accessed May 9, 2008, at http://www.babyfriendlyusa.org/eng/03.html.)
4. World Health Organization, UNICEF. Baby-friendly hospital initiative (Revised, updated and expanded for integrated care). In; 2006.
5. Murray EK, Ricketts S, Dellaport J. Hospital practices that increase breastfeeding duration: results from a population-based study. Birth 2007;34(3):202-11.
6. DiGirolamo A, Grummer-Strawn L, Fein S. Maternity care practices: Implications for breastfeeding. Birth 2001;28(2):94-100.
7. World Health Organization, Division of Child Health and Development. Evidence for the ten steps to successful breastfeeding (revised). Geneva: WHO; 1998.
8. Duyan Camurdan A, Ozkan S, Yuksel D, Pasli F, Sahin F, Beyazova U. The effect of the baby-friendly hospital initiative on long-term breast feeding. Int J Clin Pract 2007;61(8):1251-5.
9. Caldeira AP, Goncalves E. Assessment of the impact of implementing the Baby-Friendly Hospital Initiative. J Pediatr (Rio J) 2007;83(2):127-32.
10. Centers for Disease Control and Prevention. Breastfeeding-related maternity practices at hospitals and birth centers — United States, 2007. MMWR 2008;57(23):621-25. 
11. American Academy of Family Physicians. Breastfeeding (Position Paper). In; 2001.
12. American College of Nurse Midwives. Position Statement: Breastfeeding. Silver Spring, MD: American College of Nurse Midwives; 2004 Feb.
13. American College of Obstetricians and Gynecologists. Breastfeeding. Washington, DC; 2003 July.
14. American Public Health Association. American Public Health Association Policy No. 200714: A call to action on breastfeeding: a fundamental public health issue. 2007.
15. European Commission. Protection, promotion and support of breastfeeding in Europe: a blueprint for action. Dublin Castle, Ireland; 2006 June 18.
16. WHO/UNICEF. WHO/UNICEF Global Strategy for Infant and Young Child Feeding. Geneva: WHO; 2003.
17. Cattaneo A, Borgnolo G, Simon G. Breastfeeding by objectives. Eur J Public Health 2001;11(4):397-401.
18. Gartner LM, Morton J, Lawrence RA, et al. Breastfeeding and the use of human milk. Pediatrics 2005;115(2):496-506.
19. Chen A, Rogan WJ. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics 2004;113(5):e435-9.
20. Ball T, Wright A. Health care costs of formula-feeding in the first year of life. Pediatrics 1999;103(4 Pt 2):870-6.
21. Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. In: Evidence Report/Technology Assessment Number 153: Agency for Healthcare Research and Quality; April 2007.
22. World Health Organization. International Code of Marketing of Breast-milk Substitutes. Geneva: World Health Organization; 1981.