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Connecticut Breastfeeding Initiative

Potential Public Health Impact

Reach: The intervention had broad reach to maternity staff and therefore to mothers and babies. The potential reach is high, as this intervention influences hospital policies, which have the potential to reach all staff and patients. Maternity staff: A total of 583 staff were trained either by the CBI consultant or through other training programs suggested by the CBI. Overall, the various training approaches reached 82% of staff.Births: In 2009, the most recent year for which data are available, 16,948 births occurred in the ten CBI hospitals. It is estimated that, after the CBI, 58.5% of Connecticut births will occur at maternity facilities that are already Baby-Friendly designated or working towards designation as part of the CBI. Within the ten hospitals reached by the CBI, 6,659 public pay births occurred, 49.6% of the state’s public pay births. After the CBI, it is estimated that 65% of births paid for by public sources will happen in facilities already designated or working towards designation as part of the CBI. The CBI intervention provides staff training to help women initiate and continue breastfeeding, and overcome barriers to breastfeeding. Breastfeeding rates increased as a result of the Boston BFHI (a similar intervention at one hospital), and increased in particular among black women, suggesting that there is representative reach of the BFHI into populations facing disparate health risks. Also, the CBI hospitals were selected for participation based upon the number of public pay births, which increases reach to at-risk mothers and their babies.

Effectiveness: The potential effectiveness of the intervention in moving multiple hospitals along the 4-D Pathway and changing hospital level policies and practices in participating hospitals is also high. The ten hospitals made progress on the 4-D Pathway and achieved at least five of the ten required Steps. The intervention had a positive impact on maternity staff self-reported breastfeeding practices, their attitudes towards breastfeeding, and their confidence to provide breastfeeding-related care. Data were not provided on changes in mothers’ breast feeding practice but we know from prior research that implementing BFHI is associated with increased initiation and exclusivity of breastfeeding.

Adoption: Of 26 eligible hospitals (those not already BFHI designated), thirteen applied to participate in the CBI. Ten were selected and all ten participated.2

Implementation: The potential for implementation is strong. All ten hospitals implemented at least five of the Ten Steps and were working towards the remaining as of the conclusion of the project. Hospitals found it difficult to find funding to cover staff members while they attended trainings. It was also difficult to get physicians to buy into the program and to get trained. The extent to which participating hospitals used the allotted 40 consultant hours varied. Most hospitals used between 18 and 26 hours of the one-on-one consultant time. Six months into the project, the hospitals requested an in-person meeting every month. This was implemented and well-received, with an average of eight CBI hospitals present for these meetings. Counting all consultation hours (group and individual), all hospitals received or exceeded the allotted 40 hours.

Maintenance: The potential for maintenance of Baby-Friendly practices is moderate to high, and depends on a hospital’s ongoing adherence to Baby-Friendly practices. Completing the 4-D Pathway is resource and time intensive, but is a value-add to hospitals so it is worth maintaining. Therefore, becoming designated is a strong incentive for maintaining designation. On the other hand, financial and other costs involved in maintaining designation (such as training new staff and paying fees) are important considerations. Breastfeeding is a focus of the Joint Commission and the National Quality Forum, creating further incentives for hospitals to maintain their focus in these areas. In 2012, The Joint Commission recently began requiring perinatal core measures, including exclusive breastfeeding, for hospitals with over 1,100 births per year. Baby-Friendly Designation is also of great value in the profitable healthcare area of maternity care. Maintenance is further promoted by the public demanding Baby-Friendly services and practices in order to be able to choose from a variety of providers who offer the services desired.



1 Hospitals self-reported the percentage of staff trained at their hospital, which in turn was used to calculate this estimate of the percentage of staff trained across CBI hospitals.

Several other states and some cities have adopted and implemented similar systems-wide approaches to promote the Baby-Friendly approach. The CBI did not play a role in the work being undertaken elsewhere.