Poised for Change: A breastfeeding peer counseling program clears a path towards Baby-Friendly in a large urban hospital

With the goal of supporting exclusive breastfeeding among low income women in South Los Angeles, the Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center (LA BioMed) sought and received funding from First 5LA to provide new mothers with bedside breastfeeding education from trained breastfeeding peer counselors (BFPCs) at five local hospitals. This project significantly expanded upon the breastfeeding peer counseling services available through the LA BioMed WIC Program. The center post of the project is the bedside counseling provided to over 35,000 newly delivered mothers over the course of the project's 5 years of operation. Follow-up support is provided through a 1-3 day post-hospital discharge telephone call, and a breastfeeding help line which is available during normal working hours. Bilingual (Spanish/English) low-literacy educational materials are provided, as have been a variety of small incentive items. In addition, breastfeeding assistance is available at the WIC Program from trained paraprofessional staff, including WIC breastfeeding peer counselors. Most new mothers are already WIC participants; those who aren't are referred to the WIC Program. Personal breastfeeding experience and a passion to assist other mothers are the main qualifications for the BFPC position. Once hired, the BFPCs receive 5 days of training by an IBCLC with extensive experience training WIC peer counselors, followed by the 5-day UCLA Lactation Educator Training Program. A modest nurse training component was initially included in the project: a repeating one-day Breastfeeding Basics and Beyond workshop presented by two master trainers. One hundred and six nurses were trained through this program. In addition, each hospital received several sets of lactation management reference texts to be placed in nursing stations and physician areas. Midway through the project, a session of the 5-day UCLA Lactation Educator Training Program was added, in which 36 nurses participated. As the project further progressed and we learned more, nurse training began to take center stage and the BFPCs took on additional activities, to be described below. Data are collected in several ways. Bedside interviews provided evaluation data at baseline, mid-project, and in the project's final year. The data collection forms also provide assessment information to guide the BFPCs' counseling with each mother. Qualitative data were gathered from mothers and nurses at various stages of the intervention. The nurse educational programs each had its own evaluation components. Qualitative evaluation data confirm that not only have the BFPCs been instrumental in the decisions and successes of many individual mothers, but their daily presence on the postpartum units has raised awareness among the nurses of the importance of breastfeeding and of mothers' interest in breastfeeding. However, the patient education intervention did not produce the expected rise in exclusive breastfeeding at the mid-project evaluation. This negative finding was instrumental in fueling a synergy between key staff at St. Francis Medical Center and the Project's administrators. St. Francis, the largest of the participating hospitals delivering more than 6,000 babies per year, is a non-teaching facility with a private medical staff. Resulting from this collaboration has been: a large expansion of the nursing staff education component of the project; the evolution of the small breastfeeding committee initially convened to discuss and monitor project implementation into the St. Francis Baby-Friendly Task Force convened to review and revise hospital policies; and St. Francis' successful application to participate in a California Department of Health funded technical assistance project to continue on their path towards becoming a baby-friendly hospital. Project funds resulting from salary savings were used to sponsor a massive nurse training effort in which 300 St. Francis nurses participated. An unprecedented contribution on St. Francis' part to this effort was paid time for the nurses to attend the training. The training program, entitled Gentle Transitions: Enhancing Perinatal Practice in the 21st Century, was conducted by a team of trainers from the Breastfeeding Task Force of Greater LA. The curriculum focused on early attachment and the importance of skin-to-skin contact in addition to the requisite lactation management skills, and was designed to meet the didactic requirements of Baby-Friendly certification. The training served to prepare the nursing staff for the structural changes to come, the most significant of which was the hospital's retraining of its nursery nurses for assignments in labor and delivery, as stable newborns would no longer be separated from their mothers and would be transported from labor & delivery to the two postpartum units as couples. BFPC duties came to include an assignment to the antepartum unit to help prepare mothers for the skin-to-skin contact that would be offered to them, and to the labor & delivery unit to support the mother in her first breastfeeding efforts after being given the newborn by the nurse. Breastfeeding classes held on the postpartum units run in a support group style bring mothers together for mutual support and community around breastfeeding as well as education. Over the period of involvement of the Project with St. Francis, many barriers have been identified; some have been overcome; many remain to be addressed. Fundamental changes have taken place, including the development of an attitude among nursing staff that change is not only desirable but possible. There is more to be done. Additional key administrators need to become more involved, nursery nurses need to increase their comfort levels with their new responsibilities, and specific medical issues need to be addressed to the satisfaction of the physicians who deliver their patients there. We await the availability of our final Project data to assess changes in feeding practices, but are acutely aware that the major positive outcome of the Project, regardless of what the data reveal, is the forward-moving path of St. Francis Medical Center towards Baby-Friendly.