Breastfeeding has been recognized as a public health issue not just a health topic. Breastfeeding impacts long-term health outcomes. Duration of breastfeeding provides the most health benefits however, in order to impact duration rates mothers need to first initiate breastfeeding. The LDCHD is a city-county health department located in Lawrence, KS. The population of Douglas County is approximately 114,000 with over 1200 births a year. The LDCHD WIC program serves approximately 400 infants, age 0-12 months, per month. According to the CDC 2013 Report Card, the Kansas breastfeeding initiation rate was 72.9%. The LDCHD WIC program initiation rate in 2013 was 79.1%, but were not quite reaching the Healthy People 2020 goal of 81.9%. A quality improvement project, based on the PDSA model, was initiated in the spring of 2014 to identify barriers and interventions that impact breastfeeding initiation rates among the LDCHD WIC clients. Pregnant WIC clients are required to have an initial certification appointment and at least one additional nutrition education appointment before delivery. At these appointments WIC staff members are required to discuss the client’s plans for breastfeeding and offer support before and after delivery. The second appointment with the client could be scheduled as a one-on-one with a breastfeeding peer counselor, breastfeeding education class, online nutrition education lesson or a one-on-one with a nutritionist. Baseline data was collected from October 2013 to March 2014. The population studied included pregnant clients with a due date during this time frame. After reviewing the baseline data, it was discovered that of the 21 mothers that chose not to breastfeed, 71% of them did not complete a second appointment during their pregnancy discussing breastfeeding. Of the 109 mothers that did breastfeed, 90% of them did complete a second appointment discussing breastfeeding.
The breastfeeding initiation rate for Lawrence-Douglas County WIC clients in 2013 was 79.1%. After reviewing the baseline data, an improvement theory was developed using the PDSA model, identifying how the LDCHD breastfeeding initiation rate could be increased; If every pregnant WIC client has at least two appointments discussing breastfeeding before delivery, then the breastfeeding initiation rate should increase to 90% or greater. The main objective of the project was to ensure that each client was properly educated about the health benefits of breastfeeding initiation during at least two appointments with WIC, and in return the breastfeeding initiation rate would increase to 90% or greater. The population selected to receive the intervention included all LDCHD WIC clients who had a due date between May 1, 2014, and July 31, 2014. Data was collected and tracked on a Microsoft Excel spreadsheet and included demographics, breastfeeding education appointments, previous breastfeeding history and prenatal care information. Each client was followed by a WIC employee to ensure they participated in at least two appointments focusing on breastfeeding before delivery. Front-line staff had training to appropriately schedule clients for their appointments.
A total of 74 clients met the criteria for this project. Clients were contacted by phone and in person to offer a personalized approach to the client’s breastfeeding education needs. If a client was unable to be seen in person or spoken to over the phone a personalized letter with breastfeeding information was sent. The breastfeeding status of the mother-baby dyad was reviewed at her postnatal re-certification appointment and/or by the client’s breastfeeding peer counselor. There were eight clients that did not return to the WIC program after delivery. The final project cohort consisted of 66 clients. Of the 66 clients, 57 chose to breastfeed and nine did not. The final initiation rate of the project was 86.4%.
The additional success of the project stemmed from the unintentional positive impact on workforce development. Staff participation, input and buy-in on the improvement theory lead understanding the impact their actions and attitudes have on client behavior. Staff members were included in all phases of the quality improvement project. Due to increased involvement in the project staff felt that implementation had minimal impact on their daily work and gave them a focused conversation to have with the client. They felt the results were a clear validation of their effort and it was rewarding for them personally and professionally to see a positive client and community impact. Although the goal of 90% was not reached the breastfeeding initiation rates increased by 7.3% in three short months.
The website for the Lawrence-Douglas County Health Department is www.ldchealth.org.
Breastfeeding is not just a personal lifestyle choice but has been identified as a public health issue. The LDCHD's breastfeeding initiation project utilized recommendations from The Surgeon General’s Call to Action to Support Breastfeeding and Healthy People 2020. In 2011 the Surgeon General published “The Surgeon General’s Call to Action to Support Breastfeeding”. This was a detailed action plan to increase rates of breastfeeding initiation and duration to reduce overall health disparities in the United States. Secretary Kathleen Sebelius, stated in the Call to Action, “Each mother’s decision about how she feeds her baby is a personal one. Because of the ramifications of her decision on her baby’s health as well as her own, every mother in our nation deserves information, guidance, and support with this decision”.
Breastfeeding has been linked to decreased risk of many illnesses in infants including diarrhea, ear infections, SIDS and lower respiratory infections when compared to formula fed babies. Maternal health risks like certain types of cancer, postpartum depression and hypertension are also decreased in mothers who breastfeed their babies. Breastfeeding initiation and duration also is a major factor in achieving the Healthy People 2020 maternal, infant and child health objectives. Healthy People 2020 goals that LDCHD project addressed are; MICH- 1.9: Reduce the rate of infant deaths from sudden unexpected infant deaths (includes SIDS, Unknown Cause, Accidental Suffocation, and Strangulation in Bed), MICH-21: Increase the proportion of infants who are breastfed and MICH-23: Reduce the proportion of breastfed newborns who receive formula supplementation within the first two days of life.
Many studies have focused on the benefits of breastfeeding but most recently September 2014, in Pediatrics, the official journal of the American Academy of Pediatrics, a study was published that focused on the long-term effects of infant feeding. This six year study identified that there were significant health outcomes at age six that were impacted by how the child was fed during infancy. This included decreased rates of ear, throat and sinus infections. The same study also showed that there were positive impacts on the amount of fruits, vegetables and drinking water a breastfed child consumed at age six. According to the CDC, “childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years”. One of the CDC’s Winnable Battles is nutrition, physical activity and obesity. By increasing breastfeeding initiation and duration rates among infants in our communities, we can also increase long-term healthy eating outcomes and decrease obesity.
The LDCHD WIC Breastfeeding Initiation project identified a need for every client to receive consistent information, guidance and support promoting breastfeeding, regardless of their initial intentions for breastfeeding. It was imperative to the success of the project that staff be educated as well as the clients. Workforce development became an important factor in the quality improvement process. Leadership, WIC staff and front-line staff were all educated about the quality improvement project as well as the baseline data. Graphs were created to present baseline data to the leadership team. Through collaboration, many drafts were created to identify the best way to present this information to frontline staff and other stakeholders. An info graph was chosen to share the project data and staff members were trained to learn the processes that would be implemented to test the improvement theory. This simple graph made an immediate impression on front-line staff. They could easily see how a small change in their daily work could make an incredible impact. All staff members were encouraged to participate in the quality improvement project and feedback was solicited regularly. Staff felt engaged and the process created personal accountability. They then were enthusiastic about scheduling appointments correctly for clients and engaged in conversations with clients encouraging breastfeeding.
Nutrition, Physical Activity, and Obesity
Participation and feedback from other stakeholders including multiple departments within the LDCHD, our advisory council and a weekly breastfeeding support group (Breast is Best Social) was crucial. Feedback from these groups helped to streamline processes, identify any gaps in the project and include opinions from a diverse group of stakeholders. WIC staff also collaborated with the staff of our maternal child health case management program, Healthy Families Douglas County. Healthy Families Douglas County staff were notified of the project intervention. Mutual clients were identified and followed by both programs throughout the project.
LDCHD WIC staff began the quality improvement process utilizing the PDSA model in January of 2014. This approach was useful to identify an intervention that could be put into place to impact breastfeeding initiation rates. The Public Health Memory Jogger II was used to identify tools that could facilitate brainstorming activities. A cause and effect/fishbone diagram was used to identify client barriers to initiating breastfeeding. From this diagram we were able to identify barriers that could be impacted and which barriers staff had no impact on. The project focused only on barriers that could be impacted. The diagram indicated that the barriers most often expressed by our clients were related to negative perceptions about breastfeeding. It was proposed that the best way to influence a client’s perception about breastfeeding was to educate about the benefits and address any personal negative perceptions. Examples of the graphics created throughout this project can be found at: 2014 LDCHD Breastfeeding QI Project Graphics
Baseline data was then gathered to identify the number of prenatal appointments completed that specifically discussed breastfeeding. The data revealed that 21 clients chose not to breastfeed. 71% of these clients did not complete a second prenatal appointment discussing breastfeeding. Of the 109 mothers that did breastfeed, 90% did complete a second prenatal appointment discussing breastfeeding. From this baseline data, we identified that in order to positively impact our clients' perceptions about breastfeeding, breastfeeding needed to be discussed at least twice during the prenatal period. This lead to our improvement theory; If every pregnant WIC client has at least two appointments discussing breastfeeding before delivery, then the breastfeeding initiation rate should increase to 90% or greater.
The implementation strategy included; staff education and engagement, identifying the targeted client group, gathering data on the final cohort and final analysis of project data.
The intervention included; Breastfeeding Peer Counselors being assigned a client caseload to follow for the duration of the project, data was gathered on the clients by the Breastfeeding Peer Counselors and WIC Supervisor in a Microsoft Excel spreadsheet, front-line staff and WIC staff were required to schedule clients appropriately for a minimum of two appointments that discussed breastfeeding, data was collected at the first postpartum appointment regarding breastfeeding status.
A final evaluation of the data collected was completed in September 2014. Demographic data and barriers to initiation with clients studied were also evaluated to identify any trends.
No upfront costs were required to complete this project. Salary for staff assigned to the project was incorporated into regularly scheduled working hours. Data was collected in Microsoft Excel. Client data was gathered from the KWIC system that stores client records for the Kansas WIC program. Although all data needed for the project was stored in KWIC, most of the data needed to be extracted from KWIC manually per client. No current reports available in the KWIC system were able to generate the needed data. Manual extraction of the data required most of the staff hours committed to the project.
The main objective of the project was to ensure that clients were properly educated concerning the health benefits of breastfeeding initiation during at least two appointments with WIC, and in return the breastfeeding initiation rate would increase to 90% or greater. The breastfeeding initiation rate for LDCHD WIC clients in 2013 was 79.1%. The final project cohort consisted of 66 clients. Of the 66 clients, 57 chose to breastfeed and nine did not. The final initiation rate of the project was 86.4%. Although the goal of 90% was not reached the breastfeeding initiation rate increased by 7.3% in three short months.
While gathering baseline data for the project, it was identified that our current processes for prenatal education was not meeting the needs of our clients. Not all clients were receiving two or more appointments discussing breastfeeding. This was an important finding to identify what intervention would be appropriate.
The PDSA process and tools from the Public Health Memory Jogger II assisted in identifying barriers to breastfeeding initiation that could be influenced by LDCHD WIC staff.
Data was collected from the electronic records database, KWIC. This was a manual process that was very time consuming. A Microsoft Excel spreadsheet was used to track client data. Data that was collected during the project included; client ID, name, phone number, estimated delivery date, breastfeeding peer counselor assigned, appointments completed, classes attended, trimester they began on WIC, breastfeeding history, demographics and breastfeeding initiation.
An important finding to note was that the project impacted more than just breastfeeding rates. Workforce development became an unintended positive outcome related to the project. Engaging all staff in the quality improvement process, project implementation and data review was imperative to the success. Client impact relied on staff scheduling appointments appropriately so that positive exposure to breastfeeding occurred multiple times prenatally. Staff involvement created awareness how one small change can impact the long term health of our clients. The project created an environment where staff felt empowered and accountable for their actions by seeing a direct impact to client and community health.
This project showed that progress can be made through minor changes that do not have to be costly. Regular evaluation is necessary to identify if processes continue to meet clients' needs. Quarterly chart audits are completed to ensure compliance with program requirements. Evaluation of prenatal appointments related to breastfeeding and appropriate scheduling will be added to the quarterly chart audits. Monthly breastfeeding rates will continue to be evaluated to watch for changes in breastfeeding initiation rates. Breastfeeding duration rates will also continue to be reviewed to evaluate if increased breastfeeding initiation rates are leading to increased breastfeeding duration.
Working with community stakeholders and other departments in the agency enabled an unbiased perspective on the project and progress. This allowed the staff to see it from a client’s perspective and enabled us to tailor the project to meet the needs of staff and clients. Including other stakeholders also provided an experience for staff to develop collaboration skills.
No upfront costs were required to complete this project. Salary for staff assigned to the project was incorporated into regularly scheduled working hours. Regularly scheduled staff meetings were utilized to train staff and share data. Data was collected in Microsoft Excel. Client data was gathered from the KWIC system that stores client records for the Kansas WIC program. Although all data needed for the project was stored in KWIC, most of the data needed to be extracted from KWIC manually. No current reports available in the KWIC system were able to generate the needed data. Manual extraction of the data required most of the staff hours committed to the project.
With the positive results of the project, it was decided that the intervention tested will be continued and integrated into the Lawrence-Douglas County Health Department WIC program procedures.
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