A Big Solution for a Big State: How Texas is Improving Breastfeeding Rate

Longtime breastfeeding support advocate, Pamela Berens, MD, is helping Texas and NICHQ to lead the cause

May 17, 2013
By Kristina Grifantini

Pamela Berens
Pamela Berens, MD, is a faculty advisor for NICHQ's Texas Ten Step Star Achiever Breastfeeding Learning Collaborative.
As the saying goes, everything is bigger in Texas, including its effort to better support mothers who choose to breastfeed.

While around 80 percent of Texan mothers have done some breastfeeding, only 13.7 percent of those mothers are exclusively breastfeeding for the recommended six months, despite reporting a desire to breastfeed. One reason for the drop-off is a lack of support and education around breastfeeding for mothers.

Because exclusive breastfeeding for the first six months of life has immediate and long-lasting health benefits to infants, helping support mothers to breastfeed has become a public health priority. Through the Texas Ten Step Star Achiever Breastfeeding Learning Collaborative, NICHQ (National Initiative for Children’s Healthcare Quality) is helping up to 81 hospitals in Texas make changes to create settings where a woman’s choice concerning breastfeeding can be best supported, with the goal of increasing exclusive breastfeeding. The project aligns with the Department of State Health Services Texas Ten Step Program, a statewide effort to recognize and support hospitals as they improve their adherence to best breastfeeding practices. These practices, like the UNICEF/WHO Ten Steps to Successful Breastfeeding, include reducing pacifier and free formula handouts, encouraging rooming-in and skin-to-skin contact immediately after birth, and other actions shown to facilitate exclusive breastfeeding.

Pamela Berens, MD, professor at The University of Texas Health Science Center at Houston (UTHealth) Medical School and faculty advisor for the Texas Breastfeeding Learning Collaborative, helps guide the work of the participating hospitals. The Academy of Breastfeeding Medicine Fellow talks with NICHQ about the specific challenges in bringing change to the state of Texas.

The evidence of the many health benefits of exclusive breastfeeding for the first six months of life has been around for decades, and yet only in the past few years are we seeing a lot of national effort to improve. Why do you think breastfeeding education has been lacking historically?

I’ve been involved with breastfeeding education and advocacy since I completed my residency in the early ‘90s here at UTHealth. I saw a need for better education of physicians at that time. Breastfeeding training has been traditionally more common in nursing education than physician education. Why is that? There’s no good answer.

I’ve seen a great deal of improvement recently. I think that physicians now—especially obstetricians, pediatricians and family medical doctors—understand this is an important health concern and I think that the difference even in the last 10 years has been dramatic so I’m optimistic and excited about that.

Now we’ve gotten to that critical point where the importance of breastfeeding is on enough people’s radars so that we can get more focus on this particular health concern. Even though the benefits of breastfeeding have been apparent, people might not have realized how small changes can make such a big difference.

What is that status of breastfeeding in Texas and what are some of the challenges of improving breastfeeding support particular to the state?

Though the majority of Texan infants have had some breastfeeding, only 46 percent of infants were exclusively breastfed on their second day of life in 2009. But that number jumps to 74 percent if you look only at babies born in hospitals that adhere to the recommended best practices for supporting breastfeeding. With more than 10 percent of all births in the United States occurring in Texas, improvements in the state breastfeeding rates have the potential to have an impact on a national scale.

One of the things unique to Texas is that our state is so large, so there’s a huge amount of diversity in levels of breastfeeding support. There are some areas in the state that are onboard and progressive in terms of change, such as the Austin and Dallas areas. And there are other parts of our state that are at the very beginnings of their journeys in understanding the importance of making a change.

Another thing about Texas is that it’s very ethnically diverse. Some of the different ethnic groups have more obstacles to overcome in terms of breastfeeding initiation and continuation rates. We see the ethnic disparity gap narrowing at hospitals that adhere to breastfeeding guidelines, with black and Hispanic infants being nearly twice as likely to experience exclusive breastfeeding at the second day.

A particular local challenge in the Houston area is providing babies with formula supplements in hospitals, which has been shown to undermine successful breastfeeding. The averages for formula supplementation of the breastfed infant in my local area far exceed the national goal, so we have a lot of work to do regarding the in-hospital restriction of formula supplements to babies without a medical exception. We’re also focusing on other methods shown to improve breastfeeding, including facilitating skin-to-skin contact, which involves giving the baby immediately to the mother after birth.

Right now, the Texas project is working with hospitals in the Dallas area before moving to the rest of the state. What progress have you seen so far?

The hospitals seem to be working well together. We’ve had a few months worth of “tests of change”—the technique NICHQ teaches for making meaningful improvements. A lot of hospitals are focusing on increasing skin-to-skin contact right after birth, reducing use of the nursery, and creating polices around processes, such as giving out formula. We’ve had a little pushback from some individuals at a few hospitals being resistant to change, which is to be expected, but overall the feedback has been very positive. It’s been great to have the availability of shared resources and problem-solving.

One of the big challenges is that making a change in any large organization like a hospital takes time and effort. I think the Texas Breastfeeding Learning Collaborative really helps people understand how to accomplish change and the importance of what we’re doing through quality improvement training, as well as education. Having other groups in the collaborative that have gone through and resolved a particular problem is a fantastic opportunity for others to learn from them and really helps to motivate participants.

What challenge do you foresee in cutting back free formula and other improvements?

I anticipate that’s one where we’ll see a bit of resistance from the physicians. They will have to document why they’re giving away formula, so accessing formula will require an effort instead of having the little samples everywhere where people can easily get them. When you make a change to make something more restrictive, it’s not necessarily what the change is, it’s just change itself that people resist.

The hospital where you work is also participating in Best Fed Beginnings, NICHQ’s national breastfeeding support project. How has it been having a foot in both projects?

It’s been great being involved with both. They are different in that the national collaborative is really meant to get the hospitals along toward the national designation of Baby-Friendly, whereas the Texas collaborative is meant to improve the breastfeeding rates in the state and to focus on reducing breastfeeding disparities across racial/ethnic, economic and geographically disadvantaged populations. Our long-term goal is similar in that we’d like hospitals in the Texas collaborative to get to Baby-Friendly status, but our short-term goal is making more locally accessible changes in Texas, so that even a hospital that isn’t ready yet to spend the money or commitment to apply for Baby-Friendly designation can still make changes and have supportive breastfeeding policies.

Have you found the quality improvement methods taught in the two collaborative to be useful?

The big thing that NICHQ has shown me is that it’s OK to start with small changes. In the past I was more focused on the top-down instead of bottom-up approach with my changes. For instance, in my hospital we started doing skin-to-skin contact after birth in just one hospital pod and trialed it for a week to see what the concerns were. Then we expanded the scale. I think that’s worked better because you get to troubleshoot the problem on a smaller level before you make the dramatic change for everyone.