Increasing Breastfeeding Efforts through Data and Quality Improvement in the U.S.

A key performance measure for the Federal Healthy Start Program is to increase the percentage of Healthy Start child participants whose parent/caregiver reports they were breastfed or fed breast milk at 6 months. Breastfeeding has many health benefits for both infants and mothers; the American Academy of Pediatrics recommends exclusively breastfeeding for the first six months of a baby’s life.

JSI manages the Healthy Start EPIC Center, which provides capacity building assistance to all 100 Healthy Start grantees to support their achievement of program goals: improved maternal and infant health outcomes. In this capacity, JSI has worked with two Healthy Start grantees, Detroit Healthy Start and Midwest Healthy Start, to improve performance on the breastfeeding measure.

The grantees’ first step was to learn about the current rates and drivers of performance. Both grantees took an ongoing quality improvement (QI) approach that is focused on the consumer, is data-informed, and involves all staff members. JSI staff working on the Healthy Start EPIC Center recently spoke with these two QI leaders to understand how they have applied core principles of QI in their settings.

All About the Consumer

The ultimate goal of both sites’ QI efforts is to improve their participants’ health outcomes, with breastfeeding as one pathway to better outcomes overall. Mothers who breastfeed have lower risk of health problems including Type II diabetes, certain types of breast cancer, and ovarian cancer. The health benefits to babies who are breastfed include lower risks of asthma, respiratory infections, sudden infant death syndrome (SIDS), childhood obesity and Type II diabetes.

At the beginning of Midwest Healthy Start’s QI effort, about 30% of participants initiated breastfeeding, and about 1% continued breastfeeding at 6 months. “We knew we wanted to increase those rates,” said Mary Curry, ND, the Program Coordinator and Prenatal Health Coordinator at Midwest Healthy Start. Midwest Healthy Start worked with the Healthy Start EPIC Center’s Technical Assistance team, receiving one-on-one support for their QI efforts.

The other site, Detroit Healthy Start, didn’t have strong baseline data, and this was a concern to them. They opted to participate in the Healthy Start EPIC Center-sponsored initiative, the Quality Improvement Peer Learning Network (QI PLN). “When the QI PLN started, it forced us to look at our current baseline, set goals for ourselves and meet those goals,” said Aimee Surma, MS, RN, Program Evaluator for Detroit Healthy Start.

Quality Improvement Peer Learning Network (QI PLN)

In an effort to support the Healthy Start community achieve program benchmarks, the Healthy Start EPIC Center launched 7 peer learning networks (PLNs) to encourage performance improvement by applying rigorous QI practices.

Grounded in Facts and Data

The Detroit Healthy Start team evaluated their universal intake form and saw the forms as a first step to start the breastfeeding conversation by adding questions about breastfeeding. Using the Prioritization Matrix, a tool provided in the QI PLN, they explored which interventions could achieve a high impact on breastfeeding rates, at a relatively low cost. The prioritization matrix activity identified the Coeffective App as a low-resource, potentially high impact strategy, which they opted to pursue.

The Coeffective App helps pregnant women prepare to bond with their newborns, and supports them to breastfeed if they opt for it.

At Midwest Healthy Start, the team dug deeper into their data. A case management chart audit revealed that information on breastfeeding was frequently captured in the case notes, but this qualitative information was not captured in the performance measure calculation, leading to an underestimate in their breastfeeding rate. The audit also revealed that lactation consultants were more likely to ask about breastfeeding and make notes in the file than other staff member positions. A follow up conversation with staff confirmed that some staff were less comfortable having conversations around breastfeeding. The Midwest Healthy Start team developed a QI strategy to respond to these findings.

To increase staff comfort, Midwest Healthy Start purchased the H.U.G Your Baby Curriculum and held a Motivational Interviewing Community Training, an in-person workshop hosted by the Healthy Start EPIC Center that designed to enhance staff’s ability to assess clients’ readiness for behavior change and support their personal motivation for change.

The EPIC Center website really helped us to structure what elements we’d incorporate into improvement of the breastfeeding rate. We went to a conference last spring where we heard about the H.U.G Your Baby curriculum. After we went to conference, we pulled up H.U.G Your Baby [on the Healthy Start EPIC Center website] to make sure it was evidence-based. We know there's been a push to make sure everything is evidence-based and tested,” said Curry.

Involving All Staff

Involving all staff was a core concept discussed during the QI PLN sessions. Including all staff in QI efforts was essential for both sites because it increased ownership, consistency, and sustainability of needed changes. Additionally, the grantees found that having a diverse range of perspectives provided a more comprehensive understanding of the problem to address. “With breastfeeding, if Mom expressed any concerns, we wanted to make sure any team member could provide guidance until referral to lactation counselor could be initiated,” said Curry.

Meanwhile, at Detroit Healthy Start, the staff provided input on how best to integrate the breastfeeding questions in the intake form. “We always ask for their input because these changes mostly affect them. They provide solutions for what might be a better approach,” said Sharifa Harvey, LMSW, Maternal and Infant Health Coordinator at Detroit Healthy Start. Engaging staff in a participatory process has “created a better sense of community, knowing we’re all in this together,” said Surma.

Continuous and Ongoing

QI is not a one-time endeavor. Successful improvements require continuously analyzing the processes and systems that are driving outcomes, and adapting interventions to respond to these systems-level issues.

When Detroit Healthy Start studied the impact of their push for participants to use the Coffective App, they discovered that just two participants downloaded it. The team regrouped to consider what might be driving this low engagement with the App. Through this discussion, it became clear that it was challenging to get to the point in the conversation where downloading the app could be encouraged.

“We took a step back and asked, ‘what about us [the staff]?’ Are we comfortable talking about troubleshooting and encouraging clients to breastfeed? This is where we thought we could have the greatest influence on our clients,” said Surma. The team is now looking at ways to increase staff comfort with having conversations about breastfeeding with participants. A future goal is to engage participants more in QI processes. “Healthy Start is community-based. Moving forward, we really will try to engage more of our clients, and gain more input from them,” said Harvey.

Midwest Healthy Start team’s work is being considered as a pilot that can be applied to other Healthy Start performance measures. After fine-tuning the process of adding the breastfeeding question to their case management notes, they intend to repeat this process with the other benchmarks.

A Culture of Learning

“Healthy Start has a culture of continuing education, and always learning,“ said Harvey. Although updated data on breastfeeding rates is not yet available, the two sites have shown that involving all staff in taking a critical look at the root causes yields practical strategies for addressing problems. As demonstrated with Detroit Healthy Start and Midwest Healthy Start, QI methods are a valuable strategy to identify opportunities for improved performance.

Learn more about JSI’s Supporting Healthy Start Performance Project