Breastfeeding Quality Improvement Initiatives in Primary Care

In my last blog post I emphasized the fact that breastfeeding is everyone's responsibility, including all healthcare providers caring for the breastfeeding dyad. However, once a provider or practice recognizes the need to provide consistent support for better breastfeeding outcomes, it can be hard to figure out where to start. Let's take a look at Quality Improvement initiatives that can help you identify the best next steps for your practice.

Establish a culture of quality

Quality Improvement (QI) initiatives are one approach to systematically improving health outcomes. Upon identifying an area for improvement, like primary care breastfeeding support, QI includes:

1) Ongoing communication with practice, staff and patients to identify and plan for change,

2) A commitment to collecting and evaluating data, and

3) Ongoing evaluation of the effectiveness of these efforts.  

Monitoring breastfeeding rates-- a foundation for quality improvement efforts

Collecting practice breastfeeding rates is a crucial step when monitoring quality improvement initiatives focused on primary care practice breastfeeding support. For this reason, 2 out of the 6 steps in our practice needs assessment to implement team-based LC/PCP care include assessing breastfeeding rates:

• Step 1: Breastfeeding Initiation
  • A perfect starting point when considering how to improve your practice’s breastfeeding support efforts. 
  • Initiation rates provide a benchmark and help identify a time point to focus QI efforts (i.e. prenatal, hospital initiation, first weeks postpartum). Initiation is also a critical component of the calculation for business planning, budgeting resources, and planning for day to day operations. 
• Step 3: Breastfeeding Duration
• Following practice breastfeeding rates through the first year helps monitor the effectiveness of practice efforts and identify where to prioritize not only initial efforts, but also next steps.

Collecting breastfeeding rates

Collecting breastfeeding rates raises real-life, practical questions, since not all electronic health records (EHR) include this information. Ideally, all EHR routinely record breastfeeding, exclusive breastfeeding, and formula feeding rates at well child visits throughout the first two years. Given these measures are followed nationally and the information is needed to help address important topics such as infant mortality and health care disparities, we all should request breastfeeding rate collection be included in our EHR.

However if your EHR does not collect rates, you can do a manual chart review, perhaps enlisting a student for help, or consider collecting the information by a card method. This is a method described in studies conducted by primary care based research networks. It is an efficient way to gather data at a practice with minimal disruption in the day-to-day routine. For breastfeeding rate collections, you can create an index card for healthcare practitioners to record information at well visits. On the card, record age of well visit and feeding status (exclusive breastfeeding, any breastfeeding, and formula feeding). After the visit, the practitioners can drop the card in a box near the exam rooms. Your practice can collect the cards for a designated period of time and then have someone tabulate the numbers and  calculate the percentages.  

Breastfeeding goals

After committing to change, it is helpful to establish breastfeeding goals for your practice to measure progress.  Look to national recommendations for breastfeeding as a starting point. There is a long history of breastfeeding promotion for public health. National recommendations include 1) exclusive breastfeeding through six months and 2) continued breastfeeding through two years and as long as mutually desired by mother and infant. The Healthy People Initiative, a national effort that sets goals and objectives to improve the health and well-being of people in the United States, set 2030 goals of increasing rates of exclusive breastfeeding through six months to 42.4% (last rate 25.8% in 2018) and breastfeeding duration at one year to 54.1% (last rate 35% in 2018). These goals can serve as a benchmark for your practice, or you can identify different goals based on your practice needs. 

Breastfeeding duration and exclusivity require extra support

Nationwide efforts to improve breastfeeding initiation through quality improvement initiatives have been successful. Hospitals enrolled in the Best Fed Beginnings program saw an increase in Baby Friendly Hospital designation, breastfeeding initiation, and exclusivity. The Vermont Child Health Improvement Project (VCHIP) has a quality improvement project to improve breastfeeding support in collaboration with Vermont WIC and pediatric and family medicine practices. We can learn from these efforts as we work to implement change and join in the Healthy People 2030 goals to improve duration and exclusivity.

To improve breastfeeding duration we need consistent breastfeeding support to address breastfeeding challenges occurring in the first weeks after birth.  PCP support becomes critical during this time to help identify, manage, and improve access to care. Team-based care is one option to provide this support.  

Assess your practice’s needs and see what quality improvement initiative makes sense to improve the health of your families and improve breastfeeding support!

~Ann M. Witt, MD, FABM, IBCLC