Maternity Care Practices For Primary Care Every one of us has a role in that journey Why Focus on Maternity Care? The 1,000 days between a womans pregnancy and her childs 2nd birthday offer a unique window of opportunity to shape healthier and more prosperous futures. The right nutrition during this 1,000 day window can have a profound impact on a childs ability to grow, learn, and rise out of poverty. It can also shape a societys long-term health, stability and prosperity. Why 1,000 Days? During pregnancy, undernutrition can have a devastating impact on the healthy growth and development of a child. Babies who are malnourished in the womb have a higher risk of dying in infancy and are more likely to face lifelong cognitive and physical deficits and chronic health problems. For children under the age of two, undernutrition can be life-threatening. It can weaken a childs immune system and make him or her more susceptible to dying from common illnesses such as pneumonia, diarrhea and malaria. Why 1,000 Days? Improving nutrition during the critical 1,000 day window is one of the best investments we can make to achieve lasting progress in global health and development. Solutions to improve nutrition in the 1,000 day window are readily available, affordable and cost-effective. They include: Ensuring that mothers and young children get the necessary vitamins and minerals they need; Promoting good nutritional practices, including breastfeeding and appropriate, healthy foods for infants; and Treating malnourished children with special, therapeutic foods. Poverty Rates by Race and Hispanic origin Source: US Census Bureau , American Community Survey Standard of Care 1.Have a written breastfeeding policy that is routinely communicated to all health care staff. 2.Train all health care staff in skills necessary to implement this policy. 3.Inform all pregnant women about the benefits and management of breastfeeding. 4.Help mothers initiate breastfeeding within1 hour of birth. 5.Show mothers how to breastfeed and maintain lactation, even if separated from infants. 6. Give newborn infants nothing other than breastmilk, unless medically indicated. 7. Practice rooming-in 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial nipples or pacifiers. 10. Foster the establishment of breastfeeding support groups. Step 3.Inform all pregnant women about the benefits of breastfeeding. Practitioner encouragement significantly increases breastfeeding initiation among women of all social and ethnic backgrounds. Adapted from: Lu M, Lange L, Slusser W et al. Provider encouragement of breast-feeding: Evidence from a national survey. Obstetrics and Gynecology, 2001, 97: CDC-Breastfeeding Report Card Shows in each state how breastfeeding is being protected, promoted Allows comparisons across states, making it an important tool for increasing breastfeeding nationwide. Breastfeeding Report Card The Breastfeeding Report Card reports information for each state on five outcome and nine process indicators. The outcome indicators are derived from the breastfeeding goals outlined in Healthy People 2020 The process indicators measure elements of breastfeeding-friendly communities Healthy People 2020 mPINC Maternity Practices in Infant Nutrition and Care (mPINC) is a national survey of maternity care practices and policies that is conducted by the CDC every 2 years beginning in The survey is mailed to all facilities with registered maternity beds in the United States and Territories. mPINC Evidence shows that several specific practices in medical care settings can significantly affect rates of breastfeeding initiation and duration among women. Birth facility policies and practices that create a supportive environment for breastfeeding begin prenatally and continue through discharge. The mPINC survey measures infant feeding related policies and practices, showing facilities their strengths and areas that need improvement. mPINC Survey Design The mPINC survey contains 52 questions: 33 relate to hospital/birth center practices 13 relate to training, personnel, and policy 6 relate to characteristics of the hospital/birth center: Hospital Characteristics Questions from each of these sections are then organized into 7 scoring groups: 1- Labor and Delivery Care 2- Breastfeeding Assistance 3- Contact between Mother and Infant 4- Feeding of Breastfed Infants 5- Facility Discharge Care 6- Staff Training 7- Structural and Organizational Aspects of Care Delivery. The highest score possible for the mPINC survey is 100. Opportunities for Improvement in Wisconsin The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) Guidelines for Perinatal Care recommend against routine supplementation because supplementation with formula and/or water makes infants more likely to receive formula at home and stop breastfeeding prematurely. What color hat? Nearly all births in the United States occur in hospital settings, but hospital practices and policies in maternity settings can create barriers to supporting a mothers decision to breastfeed. What Women Want Information about breastfeeding and what to expect Practical help with positioning the baby to breastfeed Effective advice and suggestions Acknowledgement of their experiences and feelings Reassurance and encouragement Most Helpful Effective advice for specific concerns Encouragement to keep going Reassurance that what they are going through was normal Knowing the benefits of breastfeeding Encouragement to look after themselves, rest, eat and drink well Permission to give bottle-feeds if they wished Being able to ask questions about breastfeeding Not So Helpful Advice that did not fit with their preferences or experiences (timing and duration of feeds, positioning, etc) Not enough time or help with feeding Not feeling listened to Pressure to breastfeed Being made to feel guilty about bottle-feeding Negative attitudes towards breastfeeding Conflicting advice Insights Little information given in the antenatal period Collective loss of knowledge and experience of breastfeeding exists Need for community or network of support Give it to them straight Your experiences may interfere with your professional advice Physician knowledge and attitudes about breastfeeding AAP Recommendations Breastfeeding for all infants as indicated Breastfeeding from birth to 6 months Breastfeeding + complementary feedings from 6 to 12 months Continue beyond 12 months The main findings were that although pediatricians seem better prepared to support breastfeeding, their attitudes and commitment to breastfeeding promotion have deteriorated. Personal experience mitigates poor attitudes and seems to enhance breastfeeding practices among those surveyed. Continued efforts are necessary to enhance the promotion and support of breastfeeding offered by practicing pediatricians. Pediatricians and the Promotion and Support of Breastfeeding, Archives of Pediatric and Adolescent Medicine, Lori Feldman-Winter, MD, FAAP, Richard Schanler, MD, FAAP, Ruth Lawrence, MD, FAAP, Karen O'Connor Visitto access the article.http://archpedi.ama-assn.org/cgi/content/short/162/12/1142 MD Breastfeeding Education 25% of 1147 pediatricians in 1 national survey did not consider exclusive breastfeeding the best form of infant nutrition (1995) The Pediatric Resident Hours of Breastfeeding Training0 Number of Lactating Breasts seen0 Number of pumps operated0 The main findings were that although pediatricians seem better prepared to support breastfeeding, their attitudes and commitment to breastfeeding promotion have deteriorated. Personal experience mitigates poor attitudes and seems to enhance breastfeeding practices among those surveyed. Continued efforts are necessary to enhance the promotion and support of breastfeeding offered by practicing pediatricians. Pediatricians and the Promotion and Support of Breastfeeding, Archives of Pediatric and Adolescent Medicine, Lori Feldman-Winter, MD, FAAP, Richard Schanler, MD, FAAP, Ruth Lawrence, MD, FAAP, Karen O'Connor Visitto access the article.http://archpedi.ama-assn.org/cgi/content/short/162/12/1142 AAP Periodic Survey Exclusive breastfeeding for the first month What age to start solids? % % months 23% 6 months 70% AAP Periodic Survey Breastfeeding and formula are equally acceptable methods of feeding infants Confident that they can completely manage common breastfeeding problems 2004: 45% 2014: 40% 2004:79% 2014: 83% AAP Periodic Survey Confident in the ability too adequately address parents questions about breastfeeding: 2004: 86% 2014: 91% 2014: Eighty percent say having breastfeeding experience (either themselves or their partner) affects their interaction with mothers in their practice. Physician Personal Experiences "Even mothers who are medical professionals experience, and often cannot overcome, difficulties with breastfeeding. Women in medicine need enhanced breastfeeding support and services/resources. Advocacy is needed, in our work environments, for better breastfeeding support not only for our physician colleagues, but also for all lactating employees within our institutions." Candy Riggins, Marc B. Rosenman, and Kinga A. Szucs. Breastfeeding Medicine. June 2012, 7(3): Physician Personal Experiences Dr. MILK Mothers Interested in Lactation Knowledge Monthly meetings Web presence Facebook page Laurie B. Jones and Emily A. Mallin. Breastfeeding Medicine. June 2013, 8(3): When my first was born he wasn't transferring milk well. It was terrifying and I had no idea what I was doing. Our pediatrician gave him formula right there in the office, which made me feel like a colossal failure. But then she said, "Lots of moms get off to a rough start. You can still breastfeed!" and she gave me the number of an IBCLC who gave us great advice and had us off any supplementation within a week. I went on to breastfeed that baby until he was 3.5 years old. Just hearing the pediatrician tell me I could do it was a HUGE encouragement to me and made all the difference. I didn't realize at the time that so many pediatricians don't ever bother to address breastfeeding issues; they just tell moms to supplement and don't bother with rest. I'm so grateful mine told me where to get help and encouraged me that I could do it. Do you need to be an expert? I'm trying to think of a positive experience regarding breastfeeding with my twins' pediatrician, but all I'm coming up with is neutral ones. She never discouraged breastfeeding (even when they were older nurslings!) or raised an eyebrow, but she also wasn't really a cheerleader. And based on that I recommended her to other nursing moms... because finding a doc who didn't tell you stupid, untrue things about human lactation is a good find! Solution-Focused Miracle Question Suppose you go to bed tonight and sleep well. Sometime, in the middle of the night, a miracle happens and all the troubles that brought you here are resolved. When you wake up in the morning, whats the first small sign youd see that would make you think, Well, something must have happened- the problem is gone! You lose the will to live if you have to work through a guideline Why Mothers Stop Breastfeeding Concerns about maternal or child health infant nutrition maternal illness the need for medicine infant illness Processes associated with breastfeeding lactation and milk-pumping problems Odom, E. C., Li, R., Scanlon, K. S., Perrine, C. G., & Grummer-Strawn, L. (2013). Reasons for Earlier Than Desired Cessation of Breastfeeding. Pediatrics. doi: /peds What we can do Delaying procedures such as weighing, measuring, and administering vitamin K and eye prophylaxis (up to an hour) helps early interaction Infants are to be put to the breast as soon after birth as feasible for both mother and infant (within an hour of birth) This is to be initiated in either the delivery room or recovery room, and every mother is to be instructed in proper breastfeeding technique. Rooming in as Standard Mother-baby rooming-in on a 24-hour basis enhances opportunities for bonding, for optimal breastfeeding initiation, and for protection from infection. To avoid unnecessary separation, infant assessments in the immediate postpartum time period and thereafter are ideally performed in the mothers room. Evidence suggests that mothers get the same amount and quality of sleep whether infants room-in or are sent back to the nursery at night. Elements of a Breastfeeding- Friendly Practice Changing Roles Efficiency of care delivery has become increasingly important to providers. Need to make the best use of the limited time that can be spent with an individual patient. Increasing emphasis on team-centered care Need for efficient communication among all members of a team. Elements of a Breastfeeding-Friendly Environment Mothers Room and Waiting Room Discourage formula marketing Track breastfeeding rates in the practice Use the right growth curves Get educated and know where to refer Give encouragement and assume that all women are still breastfeeding at each visit. ABM Clinical Protocol #14: Breastfeeding-Friendly Physicians Ofce: Optimizing Care for Infants and Children, Revised 2013 Practice Changes Commit to training all office staff in skills necessary to support breastfeeding. Commit to expanding the network of support for breastfeeding by developing and nurturing reciprocal working relationships with local lactation specialists and community organizations. Counsel mothers about ways to overcome negative social pressures related to breastfeeding. Breastfeeding Friendly Office Consider IBCLC in your office IBCLCs have passed a rigorous examination that demonstrates the ability to provide knowledgeable, comprehensive lactation and breastfeeding care. Corriveau, S. K., Drake, E. E., Kellams, A. L., & Rovnyak, V. G. (2013). Evaluation of an Office Protocol to Increase Exclusivity of Breastfeeding. Pediatrics Breastfeeding Friendly Office Practice Bfmed.org, protocol #14 AAP policy Pediatricians also should serve as breastfeeding advocates and educators and not solely delegate this role to staff or nonmedical/lay volunteers. Communicating with families that breastfeeding is a medical priority that is enthusiastically recommended by their personal pediatrician will build support for mothers in the early weeks postpartum. Resources for education AAP Resources New Edition! Physician EducationCompletion of the Wellstart Modules can be used to satisfy the requirement of 3 or more hours of training for their physicians by hospitals preparing for a Baby-Friendly assessment. Plus, theyre free.