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Service Delivery Innovation Profile

Technology-Facilitated Education and Consultations With Lactation Specialists Triple Breastfeeding Rates Among Low-Income Minority Women in Primary Care Clinics


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Snapshot

Summary

Two obstetrics/gynecology clinics in the Bronx, New York, offered a breastfeeding counseling, education, and support program to low-income, minority women with healthy pregnancies who came to the clinics for prenatal care. The program included two components. The first consisted of prenatal care, provider-led, in-office education and dialogue, with discussions facilitated by automated prompts in the electronic medical record. The second consisted of inperson, onsite support from lactation consultants during two prenatal visits, an inhospital visit after delivery, and telephone-based support for up to 3 months. The program positively influenced knowledge, attitudes, and behaviors related to breastfeeding, which in turn led to a threefold rise in breastfeeding rates and an increase in breastfeeding intensity (i.e., the proportion of all feedings in which the baby receives breast milk). The program was discontinued in June 2010 when grant funding ran out. Because the Affordable Care Act designates pre- and postnatal lactation support as a reimbursable service, program developers are currently discussing opportunities to relaunch and disseminate the program.

Evidence Rating (What is this?)

Strong: The evidence consists of two randomized, controlled trials comparing breastfeeding rates and breastfeeding initiation, duration, and intensity among participants with a control group of similar women receiving usual care; additional evidence includes reports from participants on the program's impact on their knowledge, attitudes, and behaviors related to breastfeeding.
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Developing Organizations

Albert Einstein College of Medicine; Montefiore Medical Center
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Date First Implemented

2008
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Patient Population

Race and Ethnicity > Black or african american; Gender > Female; Vulnerable Populations > Impoverished; Racial minorities; Urban populations; Womenend pp

Problem Addressed

Even though breastfeeding has health benefits for both mother and infant, many women (particularly African Americans) do not breastfeed their children at recommended duration and intensity levels. Low rates are the result of multiple factors, including lack of knowledge and limited access to support from lactation consultants.
  • Significant health benefits: For infants, breastfeeding reduces the risk of ear infection, gastroenteritis, severe lower respiratory tract infections, eczema, asthma (in young children), obesity, diabetes (types 1 and 2), childhood leukemia, sudden infant death syndrome, and necrotizing enterocolitis (tissue death in the bowel).1 For mothers, breastfeeding is associated with a lower risk of type 2 diabetes, breast cancer, ovarian cancer, and postpartum depression.1
  • Suboptimal breastfeeding rates: In the United States, exclusive breastfeeding rates average only 36 percent for infants at 3 months of age and 16 percent at 6 months, far short of Healthy People 2020 goals (46 and 26 percent, respectively).2 Exclusive breastfeeding rates among African-American women are even lower—20.6 percent at 3 months and 11.7 percent at 6 months.3 In 13 States, breastfeeding rates differ by 20 percentage points or more between non-Hispanic blacks and non-Hispanic whites. Breastfeeding rates also tend to be low among young women, low-income women, and women with less education.3
  • Lack of knowledge and associated misperceptions: Low rates stem in part from a lack of knowledge about breastfeeding, which causes many new mothers to have unfounded fears and concerns about it, such as having an inadequate milk supply, the infant not being able to latch, and the assumption that an existing medical problem precludes breastfeeding. Primary care and hospital practices sometimes reinforce these fears and concerns.4
  • Limited access to lactation consultants: Primary care-based support and ongoing contact with lactation specialists certified by the International Board of Lactation Consultant Examiners can increase breastfeeding rates, yet many low-income minorities do not have access to such interventions.2 Few primary care clinics offer lactation consultant services or support women in accessing such services. As a result, women who want a consultation typically must find a lactation specialist on their own and often must pay for these services out of their own pockets, something that low-income women generally cannot do.

What They Did

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Description of the Innovative Activity

Two obstetrics/gynecology clinics in the Bronx, New York, offered a breastfeeding education, counseling, and support program to low-income, minority women with healthy pregnancies who came to the clinics for prenatal care. The program had two primary components. The first consisted of prenatal care provider-led, in-office education and dialogue, with discussions facilitated by automated prompts in the electronic medical record (EMR). The second consisted of inperson support from lactation consultants during two prenatal visits, an inhospital visit after delivery, and telephone- and text-based support for up to 3 months. Key program elements included the following:
  • Automatic enrollment of eligible women: The program served English- and Spanish-speaking women ages 18 and older in their first or second trimester of a singleton pregnancy with no known risk factors for premature birth and no known contraindications to breastfeeding. All women who met these criteria and consented were automatically enrolled in the program.
  • EMR-facilitated education: During five prenatal care visits, providers engaged in a discussion with patients about breastfeeding, aided by prompts within the EMR. As outlined below, prompts included open-ended questions designed to facilitate general discussion and specific information to share with patients.
    • Open-ended questions: At each visit, the prompt provided two or three short open-ended questions for providers to ask, with the goal of encouraging a dialogue. These questions presented breastfeeding as the norm, asking patients about their plans for breastfeeding and about any related concerns they had. Questions also gauged the patient's knowledge about breastfeeding, by asking, for example, how often a mother should breastfeed each day and how long breastfeeding should continue.
    • Targeted educational information: The prompts reminded providers to share specific, important information about breastfeeding with patients, such as guidelines and recommendations from various medical societies (such as the American Academy of Pediatrics) and professional groups.
  • Embedded lactation consultants to support mothers before and after birth: As detailed below, lactation consultants embedded within the clinics provided support during two prenatal visits, an inhospital visit right after delivery, and periodic followup for up to 3 months after delivery. Lactation consultants were credentialled by the International Board of Lactation Consultant Examiners.
    • Prenatal sessions: Lactation consultants met with patients during two prenatal sessions, with one visit focused on general education and the second on practical skills related to breastfeeding. For example, the first session explored the woman's thoughts about infant feeding as well as the opinions of her family or cultural group. The second session provided information about what to expect after delivery and breastfeeding techniques.
    • Hospital visit: The lactation consultant visited each mother in the hospital after delivery to provide hands-on education about breastfeeding techniques and to help solve any problems.
    • Periodic telephone followup: The lactation consultant phoned mothers periodically for up to 3 months after the delivery to ask about any breastfeeding successes and challenges they may be having and to offer encouragement and suggestions. If necessary, the consultant could visit the patient in her home as well.

Context of the Innovation

Albert Einstein College of Medicine of Yeshiva University in New York City is affiliated with Montefiore Medical Center, which operates four hospitals in the Bronx that collectively have 1,521 beds. Centennial Women’s Center and the Comprehensive Family Care Center (a federally qualified health center) are two of Montefiore's Bronx-based prenatal clinics that serve low- and middle-income women from a variety of ethnic groups. The two clinics care for roughly 1,500 pregnant women each year.

The impetus for this program came from Karen A. Bonuck, PhD, a professor in the Department of Family and Social Medicine and Department of Obstetrics, Gynecology, and Women's Health at Albert Einstein College of Medicine and Montefiore Medical Center. Dr. Bonuck came to appreciate the value of lactation consultant services after her first pregnancy and subsequently became interested in designing a practical, office-based program to help women of all ethnicities and socioeconomic levels in her Bronx neighborhood.

Did It Work?

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Results

The program positively influenced knowledge, attitudes, and behaviors related to breastfeeding, which in turn led to a threefold increase in breastfeeding rates and to an increase in breastfeeding intensity.
  • Positive influence on knowledge, attitudes, and behaviors: Mothers who participated in the educational component of the program felt that providers were more supportive of breastfeeding and more likely to understand its benefits, compared with mothers who did not receive such counseling.5 Mothers who received lactation counseling felt that the consultant provided useful information and helped them establish and build confidence in breastfeeding behaviors, thereby facilitating the initiation of breastfeeding and sustaining it over time.5
  • Threefold increase in breastfeeding rates: Two randomized, controlled trials both found that the program led to a threefold increase in breastfeeding rates in a study population that disproportionately included low-income minority women with low levels of education. In the first of these studies (known as Provider Approaches to Improved Rates of Infant Nutrition and Growth Study or PAIRINGS), 275 women received either usual care (no explicit breastfeeding promotion or support) or a combination of EMR-facilitated provider education and lactation consultant counseling. In the second study (Best Infant Nutrition for Good Outcomes or BINGO), 666 women received either usual care, EMR-facilitated education, lactation counseling, or a combination of education and lactation counseling. In both studies, 3-month-old infants of women who received lactation consultant counseling (with or without the education component) were three times more likely to be exclusively breastfed (PAIRINGS) or mostly breastfed, defined as 80 percent breastfeeding plus breast milk (BINGO) than infants whose mothers did not receive counseling; both studies found that the program had the same impact on the proportion of women who ever breastfed.2
  • Greater breastfeeding intensity: The PAIRINGS study found that mothers receiving the combined lactation consultant and provider counseling intervention reported greater breastfeeding intensity than did mothers not receiving such counseling.2
  • Power of results: The results were particularly meaningful given the following:
    • The trials recruited all women, not just those with prenatal intention to breastfeed.
    • Two-thirds of women were overweight or obese, a group that is at risk for limited breastfeeding and in whom interventions have generally not been effective.
    • The two sites represented a very different mix of participants, but interventions were effective in both.

Evidence Rating (What is this?)

Strong: The evidence consists of two randomized, controlled trials comparing breastfeeding rates and breastfeeding initiation, duration, and intensity among participants with a control group of similar women receiving usual care; additional evidence includes reports from participants on the program's impact on their knowledge, attitudes, and behaviors related to breastfeeding.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Obtaining grant funding: Researchers applied for and received grant funding to design an initiative and study its impact.
  • Meetings with practice-based staff: Researchers met with practice administrators, physicians, and nurses to discuss the program and secure their support for it. They also worked with practice-based staff to determine how to integrate the electronic prompts and lactation consultants with minimal disruption to existing workflows.
  • Incorporating prompts into EMR: Internal information technology (IT) staff with experience in the obstetrics/gynecology division built the electronic prompts into the practices’ existing IT systems.
  • Hiring lactation consultants: Researchers identified and hired lactation consultants using resources available through the International Lactation Consultant Association.
  • Incorporating consultants into workflow: Researchers and practice staff spent several months designing flowcharts that attempted to define how the lactation consultants would be incorporated into practice workflow but found that the actual process was more fluid and could not be captured through such flowcharts.
  • Terminating program, planning relaunch and dissemination: The program was discontinued in June 2010 when grant funding ran out. The program developers note two recent health policy "leverage points" that offer opportunities for translation and dissemination: (1) a provision of the Affordable Care Act (ACA) designates pre- and postnatal lactation support as a reimbursable service and (2) effective January 1, 2014, Medicaid can cover preventive services such as those provided by a certified lactation consultant.

Resources Used and Skills Needed

  • Staffing: The program required a principal investigator, project director, three bilingual (English/Spanish) research assistants, and three certified lactation consultants. On average, lactation consultants spent about 3 hours per participant, spread across the prenatal through 3-month postpartum time period.
  • Costs: Program costs totaled over $3 million.
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Funding Sources

National Institute of Child Health and Human Development; National Institute on Minority Health and Health Disparities
The National Institute of Child Health and Human Development (grant R01 HD04976301A2) and the National Institute on Minority Health and Health Disparities (grant 1P60 MD 000516-05) provided roughly $3 million in grant funding to support program development, implementation, and evaluation.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Ensure physician and administrator support: Nurses, lactation consultants, and other staff involved in the program may become discouraged if physicians and hospital administrators do not actively support it. To garner support, emphasize the value of lactation consultation services, including their ability to enhance the quality of care offered to pregnant women and new mothers. Physicians generally support the initiative once they realize that lactation consultants can serve as an additional source to educate and assist patients.
  • Incorporate program into existing workflow: Identify predetermined points in the care process when specific components (e.g., the electronic prompts, lactation consultant visits) will take place, but remain open to the idea of amending the workflow after implementation.
  • Train providers on how to educate patients: Providers must feel prepared to discuss the benefits of breastfeeding. During the trials, researchers found that providers often felt unprepared to perform this task. To avoid this problem, educate providers on how to discuss breastfeeding with patients, provide them with written materials to distribute to them, and develop a smooth process for handing the patient off to the lactation consultant.
  • Give lactation consultants office space: If possible, provide dedicated office space to the lactation consultants (rather than holding visits in the waiting room or offsite). This strategy ensures patient privacy and helps patients and providers perceive lactation consultations as a part of routine care.

Sustaining This Innovation

  • Do not be overwhelmed by the enormity of the task: Focus on encouraging breastfeeding with women who come to the practice, rather than worrying about breastfeeding rates in the community as a whole (which tend to be beyond the control of any one practice). Accept that not all women will choose to breastfeed, and consequently do not view the program as a failure if it does not achieve 100-percent success.
  • Identify funding allowances provided by ACA: Take advantage of reimbursement opportunities provided by the ACA, which designates pre- and postnatal lactation support as a reimbursable service.
  • Schedule consultant visits to coincide with prenatal visits: Whenever practical, offer lactation consultant appointments at the same time as prenatal visits, thus avoiding the need for a separate trip by the patient.

More Information

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Contact the Innovator

Karen A. Bonuck, PhD
Professor, Department of Family and Social Medicine and Department of Obstetrics, Gynecology, and Women's Health, Albert Einstein College of Medicine of Yeshiva University and Montefiore Medical Center
Adjunct Professor, Wurzweiler School of Social Work, Yeshiva University
1300 Morris Park Avenue
Bronx, NY 10461
(718) 430-4085
E-mail: karen.bonuck@einstein.yu.edu

Innovator Disclosures

Dr. Bonuck reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the funders listed in the Funding Sources section.

References/Related Articles

Bonuck K, Stuebe A, Barnett J, et al. Effect of primary care intervention on breastfeeding duration and intensity. Am J Public Health. 2014;104 Suppl 1:S119-27. [PubMed]

Teich AS, Barnett J, Bonuck K. Women's perceptions of breastfeeding barriers in early postpartum period: a qualitative analysis nested in two randomized controlled trials. Breastfeed Med. 2014;9(1):9-15. [PubMed]

Bonuck KA, Lischewski J, Brittner M. Clinical translational research hits the road: RCT of breastfeeding promotion interventions in routine prenatal care. Contemp Clin Trials. 2009;30(5):419-26. [PubMed]

Andaya E, Bonuck K, Barnett J, et al. Perceptions of primary care-based breastfeeding promotion interventions: qualitative analysis of randomized controlled trial participant interviews. Breastfeed Med. 2012;7(6):417-22. [PubMed]

Barnett J, Aguilar S, Brittner M, et al. Recruiting and retaining low-income, multi-ethnic women into randomized controlled trials: successful strategies and staffing. Contemp Clin Trials. 2012;33(5):925-32. [PubMed]

Bonuck KA, Trombley M, Freeman K., et al. Randomized, controlled trial of a prenatal and postnatal lactation consultant intervention on duration and intensity of breastfeeding up to 12 months. Pediatrics. 2005;116(6):1413-26. [PubMed]

Footnotes

1 Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. AHRQ Publication No. 07-E007. April 2007. Available at: http://archive.ahrq.gov/clinic/tp/brfouttp.htm.
2 Bonuck K, Stuebe A, Barnett J, et al. Effect of primary care intervention on breastfeeding duration and intensity. Am J Public Health. 2014;104 Suppl 1:S119-27. [PubMed]
3 Centers for Disease Control and Prevention. Racial and ethnic differences in breastfeeding initiation and duration, by State—National Immunization Survey, United States, 2004–2008. Morbidity and Mortality Weekly Report (MMWR). 2010;59(11):327-34. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5911a2.htm.
4 Teich AS, Barnett J, Bonuck K. Women's perceptions of breastfeeding barriers in early postpartum period: a qualitative analysis nested in two randomized controlled trials. Breastfeed Med. 2014;9(1):9-15. [PubMed]
5 Andaya E, Bonuck K, Barnett J, et al. Perceptions of primary care-based breastfeeding promotion interventions: qualitative analysis of randomized controlled trial participant interviews. Breastfeed Med. 2012;7(6):417-22. [PubMed]
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Original publication: August 13, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 13, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.