Evaluating systems interventions to increase breastfeeding among minority women utilizing mixed methods: A case study in an urban public hospital

Despite known benefits of exclusive breastfeeding, in NYC only 26% of post partum women are exclusively breastfeeding at 2 months. Minority women are significantly less likely than white women to exclusively breast feed at 2 months. To address this critical health issue, NYC Department of Health and Hospitals has implemented the UNICEF-WHO Baby Friendly Initiative (BFI) 10 step program. Since implementation of BFI in 2006 rates of exclusive breastfeeding have not significantly increased in HHC hospitals. In the spring of 2007 we began a study of the implementation of the program in one of the hospitals. Following a comprehensive review of the literature we conducted 6 focus groups with medical and nursing providers, 8 key informant interviews to validate focus group findings, 30 quantitative interviews with post partum patients and ongoing participant observations of the clinical environment. All focus groups and key informant interviews were audio-taped and transcribed verbatim. Thematic analysis and coding of data was independently conduced by 2 investigators. Coding structure was organized to reflect the goals of the evaluation. Patient surveys were assessed quantitatively. Preliminary analysis reveals high degree of knowledge, awareness and agreement that breastfeeding is a high priority. Challenges are identified at the systems level (resources, staffing, space) provider level (lack of formal clinical training, competing role demands) patient level (lack of self confidence, competing time demands) Recommendations for augmenting the intervention are discussed. Use of multiple methods of evaluation provides important complementary information to enhance intervention implementation.