Four Lessons in Optimizing Lactation and Birth Care During COVID-19 and Beyond

Interview with Catherine Sullivan

Providers worldwide are working to understand and implement changes to the Baby Friendly Hospital Initiative (BFHI) while managing the many challenges presented by the COVID-19.

At the #ILCA2020 Virtual Conference, Catherine Sullivan, Director of the Carolina Global Breastfeeding Institute (GGBI) and an assistant professor in the Department of Maternal Child Health at the Gillings School of Public Health in the University of North Carolina (UNC) at Chapel Hill in the United States, will share strategies and lessons learned from her extensive experience with the BFHI designation process. CGBI was a participant in the CDC EMPower Breastfeeding and EMPower Training Initiatives, and is now leading ENRICH Carolinas, coaching hospitals in the US states of North and South Carolina towards Baby-Friendly designation. Through their work, they have coached over 200 hospitals through the BFHI process and Step 2 implementation. 

Sullivan shared with Lactation Matters some of the lessons she and CGBI have learned, and how you can use them in transforming your hospital’s lactation support – whether towards eventual Baby-Friendly designation, or simply to “baby-friendlier” practices.

Lesson #1: An equity lens ensures that all families benefit.

We really try to use an equity lens in rolling out any programmatic activity. 

The old model was an “equality” mentality. “If we apply these ten steps across the board to everyone, everybody will achieve designation and then we will achieve breastfeeding outcomes.” But that is actually not what you see. If you haven’t addressed the equity piece, the result is a “raise all boats” mentality, rather than understanding what is needed on an individual basis. We have to be careful that we are addressing those issues that really get to the disparity. And the way to do that is to collect data and see if what you are doing is working. 

For example, if you’re looking at overall percentage of babies going skin-to-skin in the first hour, but not breaking it down by race/ethnicity, that may obscure disparities. So if 90% of all your patients are meeting that skin-to-skin goal, it could mean that 98% of a more privileged group of families were getting it – and the rest were not. I’m going to talk about how to incorporate data collection in a way that will allow you to really track those outcomes for equity.

I’m also going to talk about applying an equity lens to your training. If providers are withholding some of those best practices because of their beliefs and assumptions it can create a bigger disparity in who’s receiving that care. Along with prioritizing diversity within our team, all of our coaches are all trained in an understanding of racial equity and how racism impacts structures. They are providing technical assistance in all of those areas to make sure that the providers on the receiving end are understanding their own bias and how it has impacted the care that they’re providing.

Lesson #2: A holistic model that looks outside hospital walls is important.

We know that continuity is crucial for long-term breastfeeding success. One of the things we learned in EMPower is that we want to focus not just on getting the initiation in the hospital, but on duration and exclusivity. 

In ENRICH Carolinas, we cover other arms that help with those goals in Steps 3 and 10. We are working in the affiliated prenatal clinics and in childcare settings. That includes providing training to individuals in those settings, rather than just focusing on the hospital staff. Connecting hospitals to their community resources is essential. Hospitals are stewards of the community, and this is part of that role.

Lesson #3: The COVID-19 pandemic is an opportunity to keep the momentum going.

It’s a question people are asking right now: how do you keep the momentum going when priorities have shifted. It’s important to remember that even if the facility isn’t consciously focusing on Baby-Friendly designation right now, they are thinking a lot about best practices. We’re finding the facilities we’re coaching are asking for more visits right now, not fewer. They’re coming up for air right now and refocusing.

Safety is a key part of those competencies, and it’s a question that comes up regularly with facilities. How are we continuously monitoring families that are rooming in and doing skin to skin and that kind of thing? COVID-19 is a good opportunity to discuss safety guidelines and tie them into the conflicting information facilities have received from different agencies and organizations. 

To tie into that focus on best practices and on safety, as part of our EMPower project for CDC, we created 5-hour competency-based training for staff, including an electronic version of our competency-based training tools. We have those up on our website, and anyone can see them and play around with them. I’ll be sharing the results of our outcomes in EMPower, and how we’re rolling those lessons into ENRICH.

There are many opportunities to tie our work into current priorities.Throughout ENRICH, in every area, we’re also applying lessons learned around COVID that also are applicable for any emergency situation – Dr. Aunchalee Palmquist at CGBI has done a lot of work around infant feeding in emergencies. We also took our prenatal education live online for participating hospitals. So I’ll be talking about a number of the pivots you have to make at a time like this, and how they can become opportunities.

Lesson #4: A quality improvement mindset will help facilities worldwide as they adjust to Baby-Friendly’s revised guidelines.

Globally, BFHI is everywhere. Anyone could flip our lessons learned and replicate our model. We’ll be discussing how to roll out the interim guidance and using examples from domestic work that can be applied at the global level. When a hospital is thinking about how to achieve this, they particularly need to think about measurement and sustainability. In terms of measurement, how will they measure that they’re successful? How will they audit records? In their area, if there’s a group that’s less advantaged, how is that playing out and how do they monitor for disparities?

In terms of sustainability, quality improvement (QI) will now be incorporated into Step 1. Continuous QI for the Ten Steps is not something every country has introduced, but that is how you maintain your designation and practices once you’ve achieved them. The difference is a change toward not just focusing on designation. Any facility can focus on improvement, whether you achieve designation or not. We created a number of data markers for facilities to collect and follow that will help your progress in that QI journey.

To learn more about EMPower Training, visit:

Catherine Sullivan is the Director of the Carolina Global Breastfeeding Institute and an assistant professor in the Department of Maternal Child Health at the Gillings School of Public Health in the University of North Carolina (UNC) at Chapel Hill in the United States. In 2017, the Centers For Disease Control (CDC) in the United States engaged Sullivan and her colleagues to create a competency-based training tool for BFHI. At the conference, Sullivan will share her experience creating the tool, discuss racial equity issues, and share how her work can be applied internationally. 

Learn more about the #ILCA2020 virtual conference.

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