Baby Friendly Verses Couplet Friendly Care:

Is the Baby Friendly Movement Truly Friendly Towards the Mother-Infant Dyad?

Jasmin Smith, RN

College of Central Florida

 

 

 

 

Baby Friendly Verses Couplet Friendly Care: Is the Baby Friendly Movement Truly Friendly Towards the Mother-Infant Dyad?

            PICO: In post-partum care settings (P), does implementing baby friendly initiatives (I) compared to couplet friendly initiatives (C) affect mother-infant bonding (O)? This question was formed and utilized to guide my evidence-based search, focused on providing holistic care for the mother-infant dyad.

Purpose of the Project

       This is a topic that is near and dear to me, as a nurse and an expectant mother. When I started nursing school it was with the preconceived goal that I would someday be a labor and delivery nurse. This passion resulted from witnessing my three younger siblings be born, and particularly one nurse taking the time to explain the birthing process and different sides of the placenta to me, following my brother’s arrival when I was 12. This is a goal that I plan on transitioning to within my first five years of nursing, but for now I feel my focus needs to be on providing holistic care in the postpartum setting. Wieczorek, Schmied, Dorner, and Dür’s (2015) research shed light to evidence that acknowledged that in order to successfully implement the baby friendly initiative in the hospital setting, change and collaboration among healthcare professionals is needed.

         Ramona Mercer, a nursing theorist, is a well known advocate for supporting the transition to motherhood. Mercer promoted acknowledging the mother infant dyad as a whole, recognizing separation of the dyad negatively influenced maternal role attainment (Alligood, 2014). Mercer recognized that health includes the mother’s interpretation, as well as the care received, and the newborn’s health status as established by healthcare workers/ the mothers’ perceptions. Mercer acknowledges that a break in the mother-infant dyad, i.e. focusing on one party more than the other, could negatively influence satisfaction in maternal role development (Alligood, 2014). New studies, such as the Mother-Friendly Hospital Initiative (MFHI), conducted in Croatia, also provide supporting evidence that “true Baby-Friendly care must include the wellbeing of mothers” (Grgurić, Zakarija-Grković, Pavičić Bošnjak, & Stanojević, 2016, p. 572).

         Although my hospital has not fully adopted the baby friendly initiative (BFI), there have been portions of the Ten Steps implemented that seem to be negatively affecting our couplet patients. The purpose of this project is to discover through evidence-based research which method, baby friendly or couplet friendly, is superior to achieving holistic care in the postpartum setting and then to present these findings to my manager in hopes of providing holistic maternal-child care in Marion County.

Background

       The “Baby Friendly” initiative is a multifaceted approach to couplet care, aimed to support, facilitate, and promote breastfeeding during the postpartum stay and transition to home (Benoit & Semenic, 2014). This movement has roots tracing back to the early nineties when the World Health Organization (WHO), launched the initiative with hopes of increasing breastfeeding rates in postpartum mothers across the globe (Benoit & Semenic, 2014). Over twenty-five years later however, the initiative has yet to take hold; which spawns the question of it’s efficiency and prompts one to take a closer look at why postpartum mothers are not receptive to this “baby-friendly” movement making comments such as “baby-friendly is an oxymoron” (Tuteur, 2013) and “I felt like a failure” [when breastfeeding one’s newborn came difficultly in a Baby Friendly facility] (Grosse, 2014).

Review of the Evidence

       The main goal identified by WHO in 1991 for the BFI was to achieve exclusive breastfeeding among mothers and newborns for the first six months of life, with hopes that this habit would continue and be the sole diet for the newborn until two years of age (Wieczorek, Schmied, Dorner, & Dür, 2015). The initiative promotes implementing 10 steps in order to attain successful breastfeeding among couplets and for the organization to be accredited as Baby Friendly (Wieczorek, Schmied, Dorner, & Dür, 2015). These 10 steps are recognized as “The Ten Steps to Successful Breastfeeding,” and include the following:

1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in the skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within one hour of birth.
5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
6. Give infants no food or drink other than breast-milk, unless medically indicated.
7. Practice rooming in - allow mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no pacifiers or artificial nipples to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center.

(Baby-Friendly USA, 2012)

While the benefits of exclusive breastfeeding are uncontested as a positive choice for baby, the initiative fails to recognize the negative affects such “pressure” to exclusively breastfeed can have on moms, thus affecting the mother-infant relationship. Recent research studies have shown a better success rate with exclusive breastfeeding, with one particular hospital attaining a 76% exclusive breastfeeding rate, when implementation considers both mom and baby and gives the mom a choice (Smith, Moore, & Peters, 2012).

         In a qualitative study conducted by Benoit and Semenic, 2014, it was concluded that “participants [which included lactation consultants, nurse practitioners, nurses, and pediatricians] valued breastfeeding and family-centered care yet identified numerous contextual barriers to Baby-Friendly care including infant health status, parent/infant separation, staff workloads and work patterns, gaps in staff knowledge and skills, and lack of continuity of breastfeeding support” (p.614). It was concluded by hospital staff that the WHO’s BFI was not a realistic implementation to use in the neonatal intensive care unit (Benoit and Semenic, 2014). Participants in the study also voiced their concern that they were resistant to implementing baby friendly interventions, despite their facilities push for BFI, due to perceived gaps in knowledge, low comfort-zone, and lack of skills to do so. Evidence shows that without teamwork and clinical support it is difficult, if not impossible, to achieve interventions in the patient setting; because, if the staff does not back their interventions, patients will wonder why they should follow them?

            A cross-sectional survey utilizing both qualitative and quantitative data took a look into how mom’s giving birth in Baby Friendly hospitals viewed their experience as well as how staff member’s felt in promoting the movement. One mother responded to the survey acknowledging the obvious tension such a movement created:

[…] it was hard to be in a room of breastfeeding moms or to hear them talk about it. I felt that I had to defend my decision and yet it wasn’t a conversation I wanted to have with others. It’s a sensitive subject and I hope your initiative delivers the message of the importance of breastfeeding without minimizing those moms who choose to formula feed. We all want what is best for our children. (Pound et al., 2016, p. 652).

In another study, a young mother who struggled with breastfeeding wrote:

‘[I] felt the pressure to breast-feed was pretty overwhelming—even though it was actually something [I] wanted to do. ‘I had a lot of problems breastfeeding and they were bound and determined that no formula would be given if they had any say about it,’ she continued ‘I understand what they were doing but man, that was rough.’ (Grosse, 2014, paragraph 8)

Step six of the Ten Steps does contain the clause, “unless medically necessary,” but this seems to be lost in the BFI implementation as many healthcare workers’ frustration stem from the misconception that BFI means “breast no questions asked”. One NICU nurse responded:

I just would like to stress the importance of not forgetting that some mothers cannot breastfeed for the safety of their children (chronic addiction issues or HIV infection, etc.) and also that some babies have difficult medical needs that make the breastfeeding introduction slower (Pound et al., 2016, p. 652).

It is quite evident that a lot of frustration surrounds the BFI, and as babies cannot voice their opinion, we must use clinical rationale as nurses - as well as include the mother’s voice and opinion in implementing “baby-friendly” care. This is needed to preserve the unique bond of the mother–infant dyad, while promoting maternal satisfaction during the transition to motherhood.

Proposed Change

            The main goal from this project is to provide holistic care that is founded on evidence based practice. Evidence based care has been acknowledged as the highest level of care in the healthcare setting, facilitating the lowest costs overall, and providing superior patient outcomes (Melnyk & Fineout-Overholt, 2015). Since the evidence presented creates a discrepancy with how friendly the BFI is I feel that this warrants a look at a change of practice. My proposition for my facility, which is not currently Baby Friendly certified but adopting portions of the “Ten Steps,” is to cognizantly provide “couplet-friendly” care. By “couplet-friendly,” I am meaning care that acknowledges the mother and the baby are a intertwined dyad, which are co-dependant on one another both for sustaining life and attaining transition into motherhood/ satisfaction with the maternal role. As evidence based studies focused on considering the mother in a baby friendly setting seem almost non-existent, this proposed change is stemming from the needs I have personally encountered/observed while working in the postpartum setting. The first step needed in providing care that supports the mother-infant dyad, is getting clinical backing from obstetric and nursery affiliated staff, because implementing evidence based care requires commitment, enthusiasm, and teamwork (Melnyk & Fineout-Overholt, 2015). A recent survey I conducted among my co-workers identified that they feel a huge disconnect between the post-partum, labor & delivery, and nursery staff. Instead of providing cohesive mother-baby care, we are all acting like separate entities not affiliated with each other, and our negative attitudes towards one another are affecting our patients. In order to create a more unified environment, employee buy- in and managerial support will be needed (Melnyk & Fineout-Overholt, 2015). In order to accomplish this, I am proposing a few interventions. First off, the staff needs to see the need for evidence based care, so I will be providing inservices to all mother-baby affiliated departments. The inservices will consist of an oral/ power point presentation regarding supporting the mother-infant dyad, and then a post presentation quiz asking staff to honestly identify areas they perceive as barriers to providing couplet focused care, why they feel this disconnect exists between the units, and then what they feel is needed to accomplish this more holistic approach to care. Secondly, a unit based council will be established which will initially review these areas of concern and then transition towards teaching staff to execute evidence based care. Routine meetings, no farther spaced than a month apart, will be held and nurses, pediatricians, doctors, patient care techs, and unit managers will be encouraged to attend. This council will be useful in meeting many needs, such as identifying/proposing solutions to barriers, instructing staff how to conduct evidence based computer searches, creating a unity among departments, and ultimately fostering a paradigm shift to providing couplet friendly care. Finally, the third proposed initial intervention is more lactation support. Breastfeeding itself is not being scrutinized when we examine the BFI; only mandating it’s exclusiveness and not allowing mothers to have a choice in their newborn’s care. If mothers desire to breastfeed the hospital should be able to facilitate this through lactation support, both hands on and educational handouts. Currently we only have one internationally board certified lactation consultant (IBCLC) who works full time as our lactation specialist. This creates some issues supporting those who wish to exclusively breastfeed due to mere nurse to patient ratio alone, as many patients may call out at the same time that they are ready to feed, and the lactation consultant only being able to address one room at a time. Also, the specialist only works Monday- Friday 9-5, so weekend and nighttime needs are left up to the nursing staff. All of the postpartum nurses upon hire are required to round with the lactation nurse one shift in order to get hands on experience with lactation assistance, but one shift is not sufficient training to feel competent in facilitating successful breastfeeding, especially if the staff members themselves have never breastfed before. One re-occurring frustration is that it is often left up to the postpartum nurse, who often times has a 7-1 or 8-1 patient to nurse ratio (a topic that needs a proposed change in and of itself, but will have to be addressed at another time), to initiate and facilitate breastfeeding support. I cannot tell you how many times a couplet has been brought to me from labor and delivery and the nurse reporting off says “it’s time for them to do their first breastfeeding so you need to help them with that right now,” or the baby is under nursery census due to higher acuity needs, but well enough to be out on the floor and the nursery nurse calls and says “hey, I need you to go into room such in such and help that mom breastfeed because I don’t know how.” It is not a matter of me not wanting to help, or feeling incompetent helping, as I did receive outside lactation training prior to becoming a OB/GYN nurse, but the fact that it’s sometimes impossible to provide 1- on-1 quality breastfeeding assistance when you have six other patients needing your attention. Also, some babies require special interventions that the couplet staff have not been trained in, such as special bottles designed for cleft palette babies, and a supplemental nutrition system (SNS) that tubes the expressed breast milk (EBM) or formula to the newborn through a oral tube taped close to the nipple while trying to teach the mom and baby successful breastfeeding. When these interventions are requested by the pediatrician they are often left until the lactation specialist comes on shift, which wastes valuable time and decreases the milk supply leading to a sense of maternal frustration; because, what many mother’s do not realize is that if their breasts are not stimulated soon following birth, and they wish to breast feed, their supply will potentially be decreased or not come in. This barrier can easily be fixed, and pretty cost effectively as well. There are other nurses on our floor, one on days and two on nights, who are IBCLC certified. The proposed change is that if willing, it would be wonderful to utilize these other IBCLC nurses on some of the days that they work as additional breastfeeding resources. In order to accomplish this they would either need to be strictly working in a lactation role that shift or have a low acuity, limited patient assignment, such as three patients. Another way that would be more costly in the beginning but pay off in the end, is for our manager to partner with the current lactation consultant and come up with mandatory breastfeeding training for all obstetric and nursery staff. A proposed three different class dates, involving both oral instruction and hands on teaching, could be provided for staff both on day shift and night shift so that everyone could be reached at their convenience. These classes would incorporate breastfeeding tips, knowledge of which position to use for which mom, and when to initiate the breast pump or SNS system. These classes would be mandatory for all mother-baby affiliated nurses including L/D and nursery in order to better serve our patients and lift the burden off a single unit providing lactation assistance when the lactation consultant isn’t available.

EBP Process

Upon reviewing all the different EBP Models available to help facilitate change, I feel that the Model for Evidence Based Practice Change’s approach fits this project best. This model was revised to facilitate healthcare workers implementing evidence based change in their facility on a continuous basis (Melnyk & Fineout-Overholt, 2015). This model is cohesive and follows six steps to accomplish the desired change (Melnyk & Fineout-Overholt, 2015). Many of my co-workers, both nurses and other interdisciplinary clinicians, are resistant to change so having a simple, yet structured, model was important in choosing which model to follow. Melnyk and Fineout-Overholt (2015), identify “assessing the need for change,” as the first step of the Model for Evidence Based Practice Change. This started with the realization on my part that even though we are not baby friendly, by transitioning to a more baby-friendly approach, we were ignoring a very important part of the dyad. Also our sudden plummet in unit HCAHP scores, going from a steady 90 + % to mid 40/ 50%, triggered me to ask “what are we doing different?” Discussions among co-workers did not provide the answer, as we all feel the care we are striving to provide is not reflected but such numbers, but at the same time I couldn’t ignore the statistics. In this model once a EBP problem is identified, members formulate a PICOT question to guide them to the second step (Melnyk & Fineout-Overholt, 2015). I presented my concerns to my manager, who then asked me to educate the staff on the need for supporting the mother-infant dyad, based off my evidence based findings. As we move on to step two we are looking to “locate the best evidence” (Melnyk & Fineout-Overholt, 2015, p. 288). Lack of knowing how to conduct computer based searches on medical databases to find the latest evidence based practice is huge barrier to implementing EBP in the clinical environment. It would be part of the unit based council’s mission to make sure staff receive the proper training in this data retrieval. Once educated on executing searches, I feel a systematic review is the best method for us to take, as it transitions us to the third step of the model of critically analyzing evidence, and is a structured approach to research (Cochrane Consumer Reviews, 2017). Systematic reviews compare several studies on a particular topic in order to come to a EBP conclusion (Cochrane Consumer Reviews, 2017). Transitioning from the second to third step of the model is time consuming, due to the necessity of analyzing the material but it is needed in order to proceed. Step three of critically analyzing evidence is used by staff to determine whether there is enough evidence, and the benefits outweigh the risks, to implement change (Melnyk & Fineout-Overholt, 2015). Not one study I found, acknowledged the BFI as a superior change, but every study, paper, and web article I read did mention numerous barriers and resistant attitudes to such an intervention due to multiple factors. In step three the team must decide if the evidence supported change is feasible in the workplace (Melnyk & Fineout-Overholt, 2015), and based off my manager’s and coworker’s initial receptiveness to me speaking to them on this topic, I would conclude that fostering an atmosphere focused on supporting the mother-infant dyad is attainable overtime. Step four outlined by Melnyk & Fineout-Overholt (2015), is to design a practice change (p. 288). Prior to implementing a practice change I will collaborate with my manager, unit based council, and co-workers and use the evidence we have collected and the problem areas we have identified in order to carry out change. It is also vital to consider our population, the mother-infant dyad, and to listen to their voice as well. My manager makes daily rounds on the units and will come up with a few questions directed to elicit feedback from the mothers on how we can provide better care for the mother-newborn population during their hospitalization stay. Step five’s goal is to implement and evaluate change in practice (Melnyk & Fineout-Overholt, 2015). Most institutions following this model implement some sort of a pilot study at this point to test the population’s receptiveness/ outcomes to change prior to initiating a mandatory change to policy. This pilot effort is, like other parts of the model, geared to identify kinks and barriers to the plan and address these before they “go-live.” As addressed several times throughout this paper, clinician buy-in is important in order to create an environment that is receptive to EBP (Melnyk & Fineout-Overholt, 2015). One way to support this paradigm shift is having EBP mentors who can foster an EBP friendly environment, listen to concerns of the staff, answer these concerns and disseminate knowledge (Melnyk & Fineout-Overholt, 2015). Since we already have a unit educator, I plan on asking her to step into this role if she is willing. As far as evaluating change, I feel the best indicators of a positive change would be increased HCAHP scores and increased staff morale. The HCAHP scores are monitored quarterly, and staff feedback surveys could be conducted at this time as well. Finally, step six is integrating and maintaining change in practice (Melnyk & Fineout-Overholt, 2015). At this point of the model the desired change is presented to and reviewed by the stakeholders, and once approved by administration is incorporated into care officially via a policy and/ or procedure change (Melnyk & Fineout-Overholt, 2015). At this time I would again conduct inservices among the mother-infant units and utilize lactation’s assistance in educating all staff on breastfeeding support. One important thing to remember is that it is important to continue to monitor outcomes after integrating change and to celebrate/ acknowledge success, such as a rise in HCAHP scores, in order to foster a environment that wants to continue in supporting the change (Melnyk & Fineout-Overholt, 2015).

Outcome

The outcomes I am seeking is a rise in HCAHP scores, particularly in how efficiently patient’s feel nurses respond to their needs, a new comradery among postpartum nurses and our sister units where we are actively working as a whole and not separate entities to achieve couplet friendly care, increased acceptance and utilization of EBP achieved via creating a unit based council and EBP mentor that fosters such an environment, and staff that are equipped with the knowledge and resources necessary to implement breastfeeding assistance when needed. Change does not occur overnight, but must be initiated at some point and have an established timeline in order to be successful.

Timeline

Intervention	Months 1-3	Months 4-6	Months 7-9	Months 10-12
1. Form a UBC and Locate the best evidence	X
2. Critically analyze the evidence	X
3. Present the evidence to my Manager and have my Manager conduct patient surveys	X
4. Design practice change		X
5. Obtain approval from administration (DON)		X
6. Implement the change		X	X	X
7. Evaluate the change			X	X
8. Share outcomes with stakeholders, Acknowledge successes, and foster and EBP centered environment				X

 

Budget

            Other than the mandatory inservice training, the cost of such a change is minimal, and even the inservice cost would be justified in the long run if the change proves successful and higher HCAHP scores are received, as HCAHP scores will eventually correlate with hospital reimbursement. All of the staff needed for this endeavor is already employed by our facility, and between the three mother-infant units (labor & delivery, nursery, and postpartum) there are approximately 80 employees, comprised of 72 nurses and 8 patient care techs. With the median rate of pay of $28.50 for nurses and $12 for patient care techs the required inservices, one 30 minute course on supporting the mother infant dyad, and one 1 – 1 ½ hour course on lactation assistance, will cost less than $4,400 and that figure is if every single employee attended the training on their days off, which is highly unlikely. I would work with the unit based council to compile the inservice presentation and we would work together to evaluate the change’s outcome, which would not come at any additional cost. We already have sufficient breastfeeding tools such as Medela pumps, SNS systems, lanolin, and sterilization equipment. Quick reference guides for supporting the mother-infant dyad and breastfeeding tips will be provided to staff at the inservices, but should cost lost than $75 to print. Overall we are looking at less than $4,500 in order to accomplish this change, which may seem hefty, but overall a wise investment.

Equipment & Supplies

            Our facility already has a computer lab inside the hospital equipped with over 20, and an education modular building with an additional 10 computers that staff can utilize for EBP searches. Our unit is currently being remodeled, but has a projected completion date of late June and at that time we will have an education room, which we can use for our unit based council meetings. This time frame also gives me enough time to find out how many staff would be interested in joining a unit based council and preparing accordingly for our first meeting. As mentioned above we have sufficient breastfeeding tools that can be used as soon as staff feels competent in their use. Flyers will be distributed across the units to raise awareness of the upcoming UBC and proposed change. When it comes time for the inservices the education room will be used.

Conclusion

            Nurses are urged to provide care that is both conscious of the patient population and holistic in its approach. Evidence based care has been acknowledged as the highest level of care in the healthcare setting, facilitating the lowest costs overall, and providing superior patient outcomes (Melnyk & Fineout-Overholt, 2015). By separating the mother-infant dyad and treating it as two separate entities one cannot truly be providing holistic care as the evidence shows the dyad is co-dependant on one another for success. As Ramona Mercer acknowledged, shutting out the mother’s voice risks altering the mother-infant bond, creating maternal dissatisfaction and thus compromising the newborn’s wellbeing (Alligood, 2014). By not being trained in providing breastfeeding assistance due to lack of staff or knowledge these same trends can occur, as well as malnourishment on the baby’s end. Evidence shows that even when breastfeeding is something the mother wants to do, by strictly requiring it as the only option frustration brews, which can further alter mother-infant bonding. So in closing, I hope through this endeavor the reader can see why a couplet-friendly approach is needed in the postpartum setting and that all mother-infant nurses, whether employed in a baby-friendly facility or not, recognize and support the mother-infant dyad as a whole.

 

 

References

 

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