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North Carolina Maternity Center Breastfeeding-Friendly Designation

Evidence Summary

Strategies Used:

  • Maternity Care Practices in the Hospital Setting The North Carolina Maternity Center Breastfeeding-Friendly (NCMCBF) Designation Program encourages hospitals and maternity centers across the state to promote and support breastfeeding by facilitating changes that result in the incremental adoption of the Baby-Friendly Hospital Initiative’s Ten Steps to Successful Breastfeeding.
  • Media Campaigns and Social Marketing Promoting Breastfeeding The NCMCBF Designation Program provides public recognition of hospitals’ and maternity centers’ efforts towards becoming breastfeeding-friendly, and provides free marketing to the public about these efforts. When a facility is awarded a star-level designation, the North Carolina Division of Public Health sends the facility a designation packet that includes a certificate, a sample press release, and the NCMCBF Designation Program logo for marketing use. The logo is to be used to create brand awareness in hospitals and maternity centers and among health care providers, community partners, and the general public. In addition, the North Carolina Division of Public Health issues annual program press releases.

This intervention is also supported by the Guide to Clinical Preventive Services recommendation: “Interventions to promote and support breastfeeding have been found to increase the rates of initiation, duration, and exclusivity of breastfeeding.”

Formative work

The North Carolina Division of Public Health completed extensive formative work to develop an approach for encouraging, supporting and promoting the steps outlined in the research-tested Baby-Friendly Hospital Initiative (BFHI) in North Carolina hospitals and maternity centers. In 2006, a working group of stakeholders convened to assess statewide prevalence of breastfeeding and effective options for improving those rates, publishing their findings in the 2006 Blueprint for Action. Building on this work, a breastfeeding subcommittee of the North Carolina Child Fatality Task Force began working on what would become the NCMCBF Designation Program. The subcommittee’s formative work included meeting with directors of the North Carolina Hospital Association to gain their perspective on barriers to implementing the BFHI in their facilities as well as brainstorming workable solutions to overcoming the barriers. In addition, a pilot study was conducted in six North Carolina hospitals to assess feasibility, effects, barriers, and facilitators related to implementation of each of the 10 steps of the BFHI. This pilot - Carolina Global Breastfeeding Institute’s Breastfeeding-Friendly Healthcare project - was designed to support North Carolina hospitals serving low-income populations. The pilot study resulted in 3 publications (see “Additional Information”). The study found that certain steps of the BFHI (step #s 1, 2, 4, 6, and 9) were associated with greater breastfeeding rates across settings. The pilot study also identified barriers and facilitators to success, which North Carolina Division of Public Health used to inform the development of the NCMCBF Designation Program. The NCMCBF Designation Program was launched in August 2010.

Unlike BFHI, NCMCBF Designation Program does not require a hospital or maternity center to complete all 10 steps to get recognized. Instead, this program uses a 5 star system that recognizes hospitals and maternity centers with a star for every two steps of BFHI they complete. The NCMCBF Designation Program does not require hospitals and maternity centers to participate in BFHI, which makes the program more affordable for hospitals and maternity centers but also eliminates the requirement that hospitals and maternity centers pass a site visit to receive accreditation.

Outcome Evaluation

Evaluation of the impact of the NCMCBF Designation Program has focused on documenting the number of hospitals and maternity centers that apply for and receive stars (facilities are awarded one star for every two steps they achieve of the BFHI), and on reviewing statewide data that the CDC collects to track women’s and hospitals’ reports of breastfeeding practices.

To apply for stars, hospitals and maternity centers have to complete a detailed application form and provide documentation of their current policy and environmental supports for breastfeeding that match the requirements for specific steps in the BFHI. The number of facilities applying for and receiving stars in the NCMCBF Designation Program has increased steadily since the project’s inception in 2010. As of March 2014, of the 88 maternity center facilities in North Carolina, 30 received some level of star recognition in the NCMCBF Designation Program, including 10 facilities that reapplied for and received a higher star level from their initial designation. As of March 2014, there were two 1-star, seven 2-star, ten 3-star, seven 4-star, and four 5-star facilities in North Carolina.

The CDC collects facility-level breastfeeding data via the Maternity Practices in Infant Nutrition and Care (mPINC) survey, a national survey of maternity care practices and policies conducted every two years. Facilities’ responses are scored using an algorithm developed and reviewed by experts in the field denoting the evidence and best practices to promote breastfeeding within the health care setting.  These scores are then compiled into a summary rating, for which possible scores range from 0 to 100, with higher scores denoting better maternity care practices and policies. In North Carolina, the summary rating increased modestly from 61 to 67 between 2009 and 2011.

The CDC also publishes an annual Breastfeeding Report Card, which compiles information from several data sources on breastfeeding rates and hospital practices. Data from the CDC’s Breastfeeding Report Card provide limited evidence of an increase in women’s initiation of breastfeeding in North Carolina since the inception of the NCMCBF Designation Program. However, CDC data are for North Carolina as a whole and not just from those hospitals and maternity centers participating in the NCMCBF Designation Program, and therefore may not fully capture changes in women giving birth in those hospitals and maternity centers.

The North Carolina Division of Public Health has collected minimal data on the technical assistance it provides to hospitals and maternity centers when they apply for star designation.