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Project Description

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Nickel NC, Martens PJ, Chateau D, et al. Have We Left Some Behind? Trends in Socio-Economic Inequalities in Breastfeeding Initiation: A Population-Based Epidemiological Surveillance Study. Canadian Journal of Public Health. 2014. [Full-text]

 

The World Health Organization (WHO) and the United Nations International Children’s Emergency Fund (UNICEF) have promoted and supported breastfeeding since 1978 through ongoing development of international standards and policies (1).  In 1992, WHO/UNICEF began a world-wide accreditation process called the Baby Friendly Hospital Initiative (BFHI), which designates hospitals complying with the Ten Steps to Successful Breastfeeding and the WHO International Code of Marketing of Breast Milk Substitutes as “Baby Friendly” (2) – over 20,000 hospitals are accredited in 156 countries to date.  In Canada, the Breastfeeding Committee for Canada has designated 6 hospitals, 3 birthing centres and 13 community facilities to date as accredited (3).

A combination of policy, program and support initiatives shows the most success in influencing breastfeeding initiation and duration at a population level (4). In the one RCT of BFHI policy (5), duration and exclusivity of breastfeeding were positively affected. In Manitoba, accreditation processes have begun in several of the maternity hospitals. Even though hospitals must establish initiation rates of at least 80% prior to their assessment for accreditation, the actual impact of the process of BFHI accreditation on breastfeeding initiation rates is rarely studied as an outcome measure itself – rather the focus has been on breastfeeding duration and exclusivity.  Interestingly, two recent observational studies at MCHP have found a strong association between BFHI-like maternity policies and  increased probability of breastfeeding for women giving birth in these hospitals, even after adjusting for maternal and infant demographics and birth-related variables, socioeconomic status, geography, and maternal or infant comorbidity (6, 7). Despite efforts to encourage breastfeeding universally, studies continue to show a steep socioeconomic gradient in breastfeeding rates – the lower the SES, the lower the rates – both in rural and urban Manitoba (8, 9). Gaps have increased substantially over the past twenty years in rural/northern areas, due to increasing rates in the higher SES groups, but little or no improvement in the lowest SES group (7).

Using the Repository housed at MCHP, we will do a population-based study of all Manitoba women giving birth to healthy, full-term newborns, to examine the effect of BFHI accreditation processes on breastfeeding initiation. These processes include the ‘natural experiment’ of various stages of obtaining accreditation in hospitals and in community health programs. Progress of accreditation is being documented by Manitoba Health as part of an initiative to encourage BFHI accreditation provincially. We will study the effects of the BFHI accreditation processes on both the overall breastfeeding rates and on decreasing socioeconomic and geographic gaps in breastfeeding. 

Research Question

Does the BFHI Accreditation process increase breastfeeding rates and decrease socio-economic inequity for those giving birth in Manitoba’s maternity hospitals?
 

Hypotheses

1. Those Manitoba hospitals that are involved in the BFHI accreditation process will show more improvement in breastfeeding rates than hospitals that are demographically similar but not involved.

2. Within hospitals undergoing BFHI accreditation, the socioeconomic gap in breastfeeding rates will decrease over time, whereas the gap will not change or become worse in those hospitals not undergoing BFHI accreditation.

3. There will be a dose-response relationship with both increased breastfeeding rates and with socioeconomic gap reduction, such that those hospitals further advanced in the BFHI process will show greater change.


References

(1) Dennis CL. Breastfeeding initiation and duration: a 1990-2000 literature review. J Obstet Gynecol Neonatal Nurs 2002 January; 31(10): 12-32.

(2) Baby-friendly hospital initiative: revised, updated, and expanded for integrated care. Section 1, Background and implementation. 2009; Available at URL: http://www.breastfeedingcanada.ca/html/bfi.html. Accessed January 27, 2011.

(3) Breastfeeding Committee for Canada website (The National Authority for the WHO/UNICEF Baby FriendlyTM Hospital Initiative (BFHI) in Canada. 2011; Available at URL: http://www.breastfeedingcanada/html/bfi.html. Accessed January 27, 2011.

(4) Merten S, Dratva J, ckermann-Liebrich U. Do baby-friendly hospitals influence breastfeeding duration on a national level? Pediatrics 2005 November; 116(5):e702-e708.

(5) Kramer MS, Chalmers B, Hodnett, ED et al. Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus. JAMA 2001 January 24; 285(4):413-20.

(6) Martens PJ, Bartlett J, Burland E et al. Profile of Metis health status and health care utilization in Manitoba: A population-based study. Winnipeg, MB: Manitoba Centre for Health Policy; 2010.

(7) Martens PJ, Fransoo R, The Need to Know Team et al. What Works? A First Look at Evaluating Manitoba's Regional Health Programs and Policies at the Population Level. Winnipeg, MB: Manitoba Centre for Health Policy; 2008.

(8) Martens PJ, Brownell M, Au W et al. Health Inequities in Manitoba: Is the socioeconomic gap widening or narrowing over time? Winnipeg, MB: Manitoba Centre for Health Policy; 2010.

(9) Brownell M, De Coster C, Penfold R et al. Manitoba child health atlas update. Winnipeg, MB: Manitoba Centre for Health Policy; 2008.