A Descriptive Study of Community Input into the Evolution of John Hunter Hospital Birth Centre: Results of 'Open Entry' Criteria

Summary: The key feature of John Hunter Hospital Birth Centre is that consumer input influences the philosophy and protocols of the unit through a management executive. The executive includes representatives from all groups who use the Birth Centre, including general practitioners, visiting midwives, obstetricians and staff midwives, as well as 50% consumer representation. This has resulted in a unique Birth Centre with open and flexible entry criteria. Since its opening in February 1991,1,492 women have been admitted to John Hunter Hospital Birth Centre, and of these 1,221 (82%) gave birth there. This figure is greater than any other Birth Centre utilization rate in Australia (1–4). An examination of outcomes for 1992 indicates that neither the higher than usual utilization rate nor the open entry criteria has compromised safety for either women or their infants.     

Human Milk for Ill and Medically Compromised Infants

The use of human milk (mother's own milk and/or donor milk) in ill or medically compromised infants frequently requires some adaptation to address medical diagnoses and/or altered nutrition requirements. This tutorial describes the nutrition and immunological benefits of breast milk as well as provides evidence for the use of donor milk when mother's own milk is unavailable. Several strategies used to modify human milk to meet the medical and nutrition needs of an ill or medically compromised infant are reviewed. These strategies include (1) the standard fortification of human milk to support adequate growth, (2) the novel concept of target fortification in preterm infants, (3) instructions on how to alter maternal diet to address cow's milk protein intolerance and/or allergy in breast milk–fed infants, and (4) the removal and modification of the fat in breast milk used in infants diagnosed with chylothorax.     

Policies and Practices Related to Breastfeeding in Massachusetts: Hospital Implementation of the Ten Steps to Successful Breastfeeding1

Background: Hospital policies and practices related to breastfeeding may have long-term health effects. The Ten Steps to Successful Breastfeeding (WHO/UNICEF) provide an evidence-based standard, which may be used to assess individual hospitals. We assessed implementation, and factors related to implementation, of the Ten Steps in Massachusetts hospitals. Methods: We surveyed postpartum nurse managers at 43 (88%) of the 49 Massachusetts maternity hospitals by telephone. Survey items characterized hospital policies, breastfeeding education, and support practices. We classified hospital implementation of the Ten Steps as high, moderately high, partial, or low and used Massachusetts Department of Public Health hospital data to analyze factors related to implementation. Results: Levels of implementation of the Ten Steps ranged from high to partial. Overall, we classified implementation of 2% of hospitals as high, 58% moderately high, 40% partial, and 0% as low. Hospitals with high/moderately high levels of implementation significantly differed from hospitals with partial implementation with respect to pacifier usage (p=0.0017) and postpartum breastfeeding instruction (p=0.0001). Requirement of a physician order for formula was a statistically significant (p=0.02) predictor of Step 1 implementation but did not reach significance (p=0.14) overall. Acceptance of free formula was significantly associated (p=0.03) with overall Ten Steps implementation. Conclusion: Rates of self-reported implementation of the Ten Steps are relatively high in Massachusetts. Step 1 implementation is significantly associated with formula availability, and overall implementation with acceptance of free formula. Continued assessment is needed to confirm these results in larger samples and to examine the relationship of implementation of individual steps, breastfeeding rates, and health outcomes.Tarayn Grizzard is a 6th-year medical student pursuing a combined MD/MPH program at the Harvard Medical School and the Harvard School of Public Health. Melissa Bartick is an attending internist at Cambridge Health Alliance and an Instructor in Medicine at Harvard Medical School. She is chair of the Massachusetts Breastfeeding Coalition. Margaret Nikolov and Beth Ann Griffin are PhD candidates in the Department of Biostatistics at the Harvard School of Public Health. Kimberly Lee is an Assistant Professor of Pediatrics at the Harvard Medical School and the Medical Co-Director (Pediatrics) of Lactation Service at the Beth Israel Deaconess Medical Center, where she is also the Associate Director of the Newborn Nursery and an attending neonatologist.     

Physiologic Breastfeeding: A Contemporary Approach to Breastfeeding Initiation

Early initiation of breastfeeding has numerous benefits for maternal‐child health. Maternity care providers have been shown to play a significant role in establishing breastfeeding, yet there is limited research about clinical approaches that support breastfeeding initiation in the immediate postpartum. Traditional methods that focused on position and attachment have not demonstrated consistent, positive effects on breastfeeding outcomes. Contemporary approaches to breastfeeding initiation emphasize innate maternal and neonatal breastfeeding abilities and the importance of breastfeeding self‐efficacy, dyad‐centered care, and a supportive breastfeeding environment free from unnecessary interventions. Recommendations for clinical practice for physiologic breastfeeding initiation are provided.     

Bridging the Gap Between Textbook and Maternity Patient: A Nurse‐Developed Teaching Model for First‐Year Medical Students

Abstract: Background: Providing more opportunities for first‐year medical students to interact with patients in clinical settings is a current discussion topic in medical student education reform. Early clinical experience helps students bridge the gap between textbook and patient while observing patient‐centered care, and serves as a first step for students to develop the skills needed to work cooperatively as members of a multidisciplinary health care team. The author developed a model to provide perinatal education to first‐year medical students, consistent with the concept of interprofessional education. Methods: Primarily first‐year medical students participated in the nurse‐developed education model, a component of a noncredit extracurricular, student‐run perinatal program at a Midwestern university medical center. Students were placed at the bedsides of hospitalized women to provide support and education to them during perinatal procedures, labor, childbirth, and cesarean delivery. Results: A total of 350 students participated over a period of 13 school calendar years. Students remarked that participation in the program reinforced the importance of their concurrent anatomy and physiology classes. They observed interdependence and cooperation among the members of the health care team caring for women, and their evaluations of their experiences at the bedside were highly positive. Women consistently expressed appreciation for the additional individualized attention and education received from our student and nurse team. Conclusions: Nurses can enhance the learning of first‐year medical students in the maternity care clinical setting. This nurse‐developed education program provided students with a variety of vivid clinical experiences with maternity patients. (BIRTH 37:4 December 2010)     

Breastfeeding Trends at a Community Breastfeeding Center: An Evaluative Survey

OBJECTIVE: To evaluate the Community Breastfeeding Center's (CBC) impact on clients' breastfeeding experiences. DESIGN: Retrospective survey; participants were mailed a questionnaire. SETTING: A hospital-based drop-in center operated jointly by the Wellington-Dufferin-Guelph Health Unit and Headwaters Health Care Center and offering professional breastfeeding support and peer interaction. PARTICIPANTS: The 164 mothers of singleton births, both inpatients and community clients, who attended the CBC during a 10-month period in 1996-1997 and completed a survey. MAIN OUTCOME MEASURES: A mailed survey with forced-choice and open-ended questions. RESULTS: Of the respondents, 90.9% rated their overall CBC experience as excellent or good. Seventy-three percent of respondents breastfed for 4 months or longer. Primiparae and mothers of preterm infants tended to visit the CBC more frequently, while achieving duration rates similar to other subgroups. Returning to work was the reason most frequently cited for stopping breastfeeding (35%). CONCLUSION: The CBC is an effective community support strategy to lengthen breastfeeding duration and enhance clients' satisfaction with their breastfeeding experience.