New York State's Paid Family Leave Program is Associated with More Equitable and Increased Use of Paid Leave Following Childbirth.

OBJECTIVES: This study aimed to assess changes in paid maternity leave before and after New York's (NY) Paid Family Leave (PFL) law went into effect (1/1/2018) and changes in disparities by maternal characteristics. METHODS: We used specific data collected on maternity leaves by women who gave birth in 2016-2018 in NY State (outside NY City) participating in the Pregnancy Risk Assessment Monitoring System survey. Multiple logistic regressions were conducted to evaluate the effect of the PFL law on prevalence of paid leave taken by women after childbirth. RESULTS: After NY's PFL law went into effect, there was a 26% relative increase in women taking paid leave after childbirth. Use of paid leave after childbirth increased among all racial and ethnic groups. The increases were greater among Black non-Hispanic or other race non-Hispanic women, compared to white non-Hispanic women, suggesting that NY's law was associated with more equitable use of paid leave following childbirth. CONCLUSIONS FOR PRACTICE: Wider implementation and greater utilization of paid maternity leave policies would promote health equity and help reduce racial/ethnic disparities in maternal and child health outcomes.

Effects of New York state paid family leave on early immunizations.

OBJECTIVE: To test whether introduction of New York Paid Family Leave (NY PFL) in 2018 is associated with the timeliness of immunizations among infants whose mothers reside in NY in one of the 57 counties outside of New York City (NYC). METHODS: We use difference-in-difference methods, comparing immunization outcomes before and after NY PFL went into effect among infants born to mothers who were employed during pregnancy, and thus likely to be affected by NY PFL, vs. mothers who were not employed during pregnancy and thus unlikely to be affected. Data come from two administrative sources: (1) NYS Vital Statistics birth data; and (2) the NYS Immunization Information System (NYSIIS). RESULTS: Our findings suggest that NY PFL is associated with small increases in the probability that firstborn infants have had all immunizations on time at the ages of two and four months. We do not find statistically significant effects of NY PFL on immunization outcomes among higher birth order children. CONCLUSIONS: Our findings suggest that NY PFL led to small improvements in the timeliness of early immunizations among firstborn infants.

First-Year Enrollment and Utilization of New York State Paid Family Leave: 2018.

CONTEXT: The New York Paid Family Leave (NYPFL) law was passed in April 2016 and took effect January 1, 2018. Expanding paid family leave (PFL) coverage has been proposed as a public health strategy to improve population health and reduce disparities. OBJECTIVE: To describe first-year enrollment in NYPFL and to evaluate utilization of NYPFL benefits. DESIGN: Observational study. SETTING: New York State. PARTICIPANTS: Employees enrolled in the NYPFL program (N = 8 528 580). METHODS: We merged NYPFL enrollment and claim data sets for 2018. Descriptive analysis and multiple logistic regression models were used to assess utilization by demographic variables and business size. MAIN OUTCOME MEASURES: Utilization and duration of NYPFL to bond with a newborn or care for a family member differed by employees' age, sex, race and ethnicity, residence, income, and business size. RESULTS: Approximately 90% of working New Yorkers (N = 8 528 580) were enrolled in NYPFL. First-year utilization of PFL for newborn bonding and family care (9.4 and 4.0 per 1000 employees, respectively) was higher than comparable state PFL programs in California, New Jersey, or Rhode Island. An estimated 38.5% of employed women in New York utilized PFL for newborn bonding. Employees who worked at small businesses (1-49 employees) had lower utilization of PFL. Employees with lower incomes were more likely to claim PFL and employees of color or with lower incomes were more likely to take the maximum 8 weeks of PFL. CONCLUSIONS: These findings suggest that state PFL programs increase equity in employment benefits. Wider adoption of state/federal PFL programs could help reduce health disparities and improve maternal and infant health outcomes.

New York State Paid Family Leave Law Associated with Increased Breastfeeding Among Black Women.

Background: While breastfeeding has increased during the past 50 years, disparities continue, with Black women having the lowest rates. Use of paid leave has been associated with longer breastfeeding duration. Objective: Evaluate the impact of New York (NY)'s Paid Family Leave (PFL) law on breastfeeding, after it became effective on January 1, 2018. Materials and Methods: Women in NY (excluding NY City), who gave birth in 2016-2019 and completed the Pregnancy Risk Assessment and Monitoring System (PRAMS) survey, were included. Data from PRAMS and the NY State Expanded Birth Certificate were combined. Changes in breastfeeding initiation and duration and use of paid leave were compared, before and after NY's PFL law became effective, with separate analysis by sociodemographic factors. Results: Before NYPFL, Black women were least likely to initiate breastfeeding and breastfed for the shortest duration. After NYPFL went into effect, breastfeeding initiation and duration to 8 weeks increased for Black women, but not for other racial/ethnic groups; these findings persisted after adjustment for sociodemographic factors. Use of paid leave after childbirth increased 15% overall, with greater increases among Black women and Hispanic women. Conclusions: Implementation of the NYPFL law was associated with increased breastfeeding among Black women and increased use of paid leave by all. Greater increases in breastfeeding among Black women significantly reduced breastfeeding disparities by race/ethnicity. More widespread implementation of PFL programs in the United States would promote equity in the use of paid leave, which could reduce disparities in breastfeeding initiation and duration and possibly improve infant and maternal health outcomes.

Variation in Formula Supplementation of Breastfed Newborn Infants in New York Hospitals.

OBJECTIVES: We examined the variation between 126 New York hospitals in formula supplementation among breastfed infants after adjusting for socioeconomic, maternal, and infant factors and stratifying by level of perinatal care. METHODS: We used 2014 birth certificate data for 160 911 breastfed infants to calculate hospital-specific formula supplementation percentages by using multivariable hierarchical logistic regression models. RESULTS: Formula supplementation percentages varied widely among hospitals, from 2.3% to 98.3%, and was lower among level 1 hospitals (18.2%) than higher-level hospitals (50.6%-57.0%). Significant disparities in supplementation were noted for race and ethnicity (adjusted odds ratios [aORs] were 1.54-2.05 for African Americans, 1.85-2.74 for Asian Americans, and 1.25-2.16 for Hispanics, compared with whites), maternal education (aORs were 2.01-2.95 for ≤12th grade, 1.74-1.85 for high school or general education development, and 1.18-1.28 for some college or a college degree, compared with a Master's degree), and insurance coverage (aOR was 1.27-1.60 for Medicaid insurance versus other). Formula supplementation was higher among mothers who smoked, had a cesarean delivery, or diabetes. At all 4 levels of perinatal care, there were exemplar hospitals that met the HealthyPeople 2020 supplementation goal of ≤14.2%. After adjusting for individual risk factors, the hospital-specific, risk-adjusted supplemental formula percentages still revealed a wide variation. CONCLUSIONS: A better understanding of the exemplar hospitals could inform future efforts to improve maternity care practices and breastfeeding support to reduce unnecessary formula supplementation, reduce disparities, increase exclusive breastfeeding and breastfeeding duration, and improve maternal and child health outcomes.

Admission Laboratory Results to Enhance Prediction Models of Postdischarge Outcomes in Cardiac Care.

Predictive modeling for postdischarge outcomes of inpatient care has been suboptimal. This study evaluated whether admission numerical laboratory data added to administrative models from New York and Minnesota hospitals would enhance the prediction accuracy for 90-day postdischarge deaths without readmission (PD-90) and 90-day readmissions (RA-90) following inpatient care for cardiac patients. Risk-adjustment models for the prediction of PD-90 and RA-90 were designed for acute myocardial infarction, percutaneous cardiac intervention, coronary artery bypass grafting, and congestive heart failure. Models were derived from hospital claims data and were then enhanced with admission laboratory predictive results. Case-level discrimination, goodness of fit, and calibration were used to compare administrative models (ADM) and laboratory predictive models (LAB). LAB models for the prediction of PD-90 were modestly enhanced over ADM, but negligible benefit was seen for RA-90. A consistent predictor of PD-90 and RA-90 was prolonged length of stay outliers from the index hospitalization.

Adding Laboratory Data to Hospital Claims Data to Improve Risk Adjustment of Inpatient/30-Day Postdischarge Outcomes.

Numerical laboratory data at admission have been proposed for enhancement of inpatient predictive modeling from administrative claims. In this study, predictive models for inpatient/30-day postdischarge mortality and for risk-adjusted prolonged length of stay, as a surrogate for severe inpatient complications of care, were designed with administrative data only and with administrative data plus numerical laboratory variables. A comparison of resulting inpatient models for acute myocardial infarction, congestive heart failure, coronary artery bypass grafting, and percutaneous cardiac interventions demonstrated improved discrimination and calibration with administrative data plus laboratory values compared to administrative data only for both mortality and prolonged length of stay. Improved goodness of fit was most apparent in acute myocardial infarction and percutaneous cardiac intervention. The emergence of electronic medical records should make the addition of laboratory variables to administrative data an efficient and practical method to clinically enhance predictive modeling of inpatient outcomes of care.

Impact of State Legislation on Hospital Breastfeeding Support in New York.

OBJECTIVE: The purpose of this study was to evaluate whether 2 state mandates, both implemented in 2010, had an impact on NY hospitals providing maternity care. Specifically, we measured changes in hospital staff's awareness, attitudes, and promotion of breastfeeding (BF), maternity care practices, and hospital breastfeeding policies and tested whether they were related to implementation of the Breastfeeding Mothers' Bill of Rights or the mandate for public reporting of hospital-specific BF measures. DESIGN: In 2009 and 2011, written hospital BF policies were collected and evaluated using a 28-item review tool and hospital BF surveys were conducted. The surveys assessed hospital culture and staff attitudes associated with BF promotion and support and recommended maternity care practices. SETTING AND PARTICIPANTS: NY hospitals providing maternity care services and hospital staff. MAIN OUTCOMES MEASURE: Changes over time in hospital BF policies (BF policy score) and implementation of recommended maternity care practices (9 of Ten Steps to Successful BF) were evaluated. The relationships and correlations between these changes in staff awareness, hospital culture, and BF promotion were determined. RESULTS: Between 2009 and 2011, there were increases in BF policy scores, maternity care practices implemented, and lactation staff (P < .001). Greater awareness by hospital administrators of BF measures was associated with more emphasis in promoting BF (P = .02). Hospitals reporting much more emphasis in promoting BF or reporting large changes in organizational culture had greater increases in BF policy scores and the recommended maternity care practices implemented (P < .05). CONCLUSION: These findings suggest that state mandates requiring key BF policies and support in hospitals and public reporting of BF rates may have led to increased emphasis and promotion of BF, improvement in hospital BF policies, and increased implementation of maternity care practices supporting BF. Implementation of similar policies by other states, combined with rigorous evaluation, is needed to replicate these findings and assess the long-term impact on maternal and infant health outcomes.

The Impact of Hospital Resources and Availability of Professional Lactation Support on Maternity Care: Results of Breastfeeding Surveys 2009-2014.

BACKGROUND: Breastfeeding provides maternal and infant health benefits. Maternity care practices encompassed in the 10 Steps to Successful Breastfeeding are positively associated with improved breastfeeding outcomes. This study assessed changes in maternity care practices and lactation support. MATERIALS AND METHODS: In 2009, 2011, and 2014, New York (NY) hospitals providing maternity care services were surveyed to assess the implementation of 9 of the 10 Steps to Successful Breastfeeding, professional lactation support, distribution of formula and discharge packs, and patient and hospital barriers to breastfeeding success. Generalized estimating equations were used to evaluate changes over time. RESULTS: Surveys were completed by 138/138 (2009), 128/129 (2011), and 125/125 (2014) NY hospitals. During this time period, the percent of hospitals reporting implementation of Steps 2, 4, 6, or 9 increased, and the mean number of 9 steps implemented increased from 4.3 to 5.3. Hospitals distributing formula samples at discharge to breastfeeding mothers decreased significantly from 39 (32%) to 3 (2%). Professional lactation staffing ratios (N/1,000 births) of both International Board Certified Lactation Consultants and Certified Lactation Counselors increased between 2009 and 2011, but then decreased between 2011 and 2014. Reported barriers to breastfeeding support changed, with reductions in mixed messages from staff, but increases in lack of financial resources for breastfeeding support, inadequate prenatal education, mothers not being prepared, and family not being receptive to breastfeeding. CONCLUSIONS: Between 2009 and 2014, NY hospitals reported increased barriers and a reduction in professional lactation support, which may have contributed to the limited improvements in breastfeeding support.

Public Reporting of Hospital-Specific Breastfeeding Measures.

BACKGROUND: Establishing breastfeeding in the first days of an infant's life is important for longer term success in breastfeeding. In 2009, New York State (NYS) was the second state to require maternity care facilities to collect infant feeding information and to publicly disseminate hospital-specific infant feeding statistics. Public reporting of these statistics as performance measures is a strategy to prompt hospitals to improve breastfeeding support. OBJECTIVE: This qualitative study sought to explore how maternity care administrators and clinical staff responded to the mandate for publicly reported performance measures and whether they used this information to improve maternity care practices. METHODS: This study used a stratified random sample of NYS hospitals with maternity care units. Participants were recruited by email and telephone calls. A total of 25 hospitals participated in the study, and 37 hospital administrators and staff completed in-depth interviews by telephone. The interviews were analyzed using an explanatory framework in NVivo 8. RESULTS: Publicly reported hospital-specific breastfeeding measures increased attention to breastfeeding performance. Hospital administrators and staff reported comparing their relative rankings to other hospitals in the state. Some hospitals used publicly reported breastfeeding measures to monitor performance, whereas others were prompted to generate additional measures for more frequent monitoring. Hospitals with relatively low breastfeeding statistics took certain actions to improve their maternity care practices to support breastfeeding. Limitations of the usefulness of publicly reported measures were reported by interview participants. CONCLUSION: Publicly reported, hospital-specific breastfeeding measures may prompt hospitals to monitor and improve maternity care practices related to supporting breastfeeding.

Breastfeeding-Friendly Erie County: Establishing a Baby Café Network.

Community-based lactation support groups help improve breastfeeding duration by offering practical peer and professional help and counseling through the sharing of information and experiences in a relaxed setting. The objective of this project, funded by the Centers for Disease Control and Prevention, was to establish at least 5 Baby Cafés in organizations that reach low-income women living in a high-need, racially/ethnically diverse, urban county with 1 of the lowest rates of breastfeeding initiation, exclusivity, and duration in New York. The New York State Department of Health partnered with the P(2) Collaborative of Western New York and United Way of Buffalo & Erie County's Healthy Start Healthy Future for All Coalition to facilitate the recruitment of 11 community-based agencies in Erie County, New York, to provide and/or enhance breastfeeding support. Six organizations were funded to establish licensed Baby Cafés, which provided skilled, free-of-charge, drop-in lactation support and counseling to mothers at easily accessible locations. The organizations provided staff training and staffing at the Baby Cafés, established coordinated hours of operation between all locations, and jointly marketed their services. Collectively, the 6 Baby Cafés provided 11 drop-in sessions per week. During the 7-month start-up time, mothers/babies made 276 visits and they averaged 75 visits per month, representing at least 150 clients. After the funding ended, 5 organizations continued to support and staff the Baby Cafés whereas 1 organization added another Baby Café. Future evaluation is needed to determine their effect on breastfeeding exclusivity and duration.

Breastfeeding-Friendly Erie County: Establishing the New York State Breastfeeding Friendly Practice Designation.

BACKGROUND: Primary care providers play an important role in encouraging and counseling pregnant and postpartum women to successfully breastfeed. OBJECTIVE: One objective of this 1-year grant was to establish the Breastfeeding Friendly Practice Designation criteria and process to identify and designate at least 5 primary care practices as New York State Breastfeeding Friendly Practices in a high-need, racially/ethnically diverse, urban county in New York with very low prevalence of breastfeeding initiation, exclusivity, and duration. METHODS: A partnership between the New York State Department of Health and the P(2) Collaborative of Western New York and United Way of Buffalo & Erie County's Healthy Start Healthy Future for All Coalition facilitated the development of the New York State Ten Steps to a Breastfeeding Friendly Practice, accompanying implementation guide, designation criteria, and model office policies. Practice staff and providers received on-site training and materials and participated in a virtual learning network to share their experiences, celebrate successes, and overcome challenges in implementing system changes. Practice staff completed a self-assessment survey at baseline and after implementation of the Ten Steps and submitted their written office breastfeeding policy for review. RESULTS: Fourteen practices met the criteria for designation and were recognized by the New York State Health Commissioner. CONCLUSION: The number of practices designated as Breastfeeding Friendly far exceeded the grant objective. Future efforts are directed at expanding this initiative statewide and determining the impact of the designation on breastfeeding outcomes.

Can Adding Laboratory Values Improve Risk-Adjustment Mortality Models Using Clinical Percutaneous Cardiac Intervention Registry Data?

BACKGROUND: Registry data for percutaneous coronary intervention (PCI) are being used in New York and Massachusetts and by the American College of Cardiology to risk-adjust provider mortality rates. These registries contain very few numerical laboratory data for risk adjustment. METHODS: For 20 hospitals, New York's PCI registry data from 2008-2010 were used to develop statistic models for predicting in-hospital/30-day mortality with and without appended laboratory data. Discrimination, calibration, correlation in hospital's risk-adjusted mortality rates, and differences in hospital quality outlier status were compared for the two models. RESULTS: The discrimination of the risk-adjustment models was very similar (C-statistic = 0.898 from the registry model vs C-statistic = 0.908 from the registry/laboratory model; P=.40). Most of the non-laboratory variables in the two models were identical, except that the registry model contained malignant ventricular arrhythmia and the registry/laboratory model contained previous coronary artery bypass surgery. The registry/laboratory model also contained albumin ≤3.3 g/dL, creatine kinase ≥600 U/L, glucose ≥270 mg/dL, platelet count >350 k/µL, potassium >51 mmol/L, and partial thromboplastin time >40 seconds. The addition of laboratory data did not affect outlier status for better-performing hospitals, but there were differences in identifying the hospitals with significantly higher risk-adjusted mortality rates. CONCLUSIONS: Adding laboratory data did not significantly improve the risk-adjustment mortality models' performance and did not dramatically change the quality assessment of hospitals. The pros and cons of adding key laboratory variables to PCI registries require further evaluation.

Implementing Legislation to Improve Hospital Support of Breastfeeding, New York State, 2009-2013.

INTRODUCTION: Increasing breastfeeding is a public health priority supported by strong evidence. In 2009, New York passed Public Health Law § 2505-a, requiring that hospitals support the World Health Organization's (WHO's) recommended "Ten Steps for Successful Breastfeeding" (Ten Steps). This legislation strengthened and codified existing New York State's hospital perinatal regulations. The purpose of this study was to assess hospital policy compliance with New York laws and regulations related to breastfeeding. METHODS: In 2009, 2011, and 2013, we collected written breastfeeding policies from 129 New York hospitals that provided maternity services. A policy review tool was developed to quantify compliance with the 28 components of breastfeeding support specified in New York Codes, Rules, and Regulations and the new legislation. In 2010 and 2012, hospitals received individual feedback from the New York State Department of Health, which informed hospitals in 2012 that formal regulatory enforcement, including potential fines, would be implemented for noncompliance. RESULTS: The number of components included in hospital policies increased from a mean of 10.4 in 2009, to 16.8 in 2011, and to 27.1 in 2013) (P < .001); a greater increase occurred from 2011 through 2013 than from 2009 through 2011 (P < .001). The percentage of hospitals with fully compliant policies increased from 0% in 2009, to 5% in 2011, and to 75% in 2013 (P < .001), and the percentage that included all WHO's 10 steps increased from 0% to 9% to 87%, respectively (P < .001). CONCLUSION: Although legislation or regulations requiring certain practices are important, monitoring with enforcement accelerates, and may be necessary for, full implementation. Future research is needed to evaluate the impact of improved hospital breastfeeding policies on breastfeeding outcomes in New York.

The value of adding laboratory data to coronary artery bypass grafting registry data to improve models for risk-adjusting provider mortality rates.

BACKGROUND: Clinical databases are currently being used for calculating provider risk-adjusted mortality rates for coronary artery bypass grafting (CABG) in a few states and by the Society for Thoracic Surgeons. These databases contain very few laboratory data for purposes of risk adjustment. METHODS: For 15 hospitals, New York's CABG registry data from 2008 to 2010 were linked to laboratory data to develop statistical models comparing risk-adjusted mortality rates with and without supplementary laboratory data. Differences between these two models in discrimination, calibration, and outlier status were compared, and correlations in hospital risk-adjusted mortality rates were examined. RESULTS: The discrimination of the statistical models was very similar (c = 0.785 for the registry model and 0.797 for the registry/laboratory model, p =0.63). The correlation between hospital risk-adjusted mortality rates by use of the two models was 0.90. The registry/laboratory model contained three additional laboratory variables: alkaline phosphatase (ALKP), aspartate aminotransferase (AST), and prothrombin time (PT). The registry model yielded one hospital with significantly higher mortality than the statewide average, and the registry/laboratory model yielded no outliers. CONCLUSIONS: The clinical models with and without laboratory data had similar discrimination. Hospital risk-adjusted mortality rates were essentially unchanged, and hospital outlier status was identical. However, three laboratory variables, ALKP, AST, and PT, were significant independent predictors of mortality, and they deserve consideration of addition to CABG clinical databases.

Association of prenatal participation in a public health nutrition program with healthy infant weight gain.

OBJECTIVES: We tested the hypothesis that early enrollment in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is associated with a reduced risk of rapid infant weight gain (RIWG). METHODS: We used a longitudinal cohort of mother-infant pairs (n = 157,590) enrolled in WIC in New York State from 2008 to 2009 and estimated the odds of RIWG, defined as a 12-month change in weight-for-age z score of more than .67, comparing infants of mothers enrolled during the first, second, or third trimester of pregnancy with those who delayed enrollment until the postpartum period. RESULTS: After adjusting for potential confounders, the odds of RIWG (odds ratio [OR] = 0.76; 95% confidence interval [CI] = 0.74, 0.79) were significantly lower for infants of women enrolling during the first trimester versus postpartum. Birth weight-for-gestational-age z score (OR = 0.33; 95% CI = 0.32, 0.33) attenuated the estimate of prenatal versus postpartum enrollment (OR = 0.92; 95% CI = 0.88, 0.95; first-trimester enrollees). CONCLUSIONS: The results demonstrate that prenatal WIC participation is associated with reduced risk of RIWG between birth and age 1 year. Improved birth weight for gestational age may be the mechanism through which early prenatal WIC enrollment protects against RIWG.

There Is More to Transparency than Meets the Eye: The Impact of Mandatory Disclosure Laws Aimed at Promoting Breastfeeding.

Requiring hospitals to inform patients of clinical best practices and to disclose performance data are two common regulatory strategies for improving healthcare. Proponents of such mandatory disclosure laws--sometimes referred to as "targeted transparency "--argue that they increase patient awareness and thereby create reputational incentives for hospitals to improve their performance. Evaluation of targeted transparency typically focuses on patient responses to information and changes in hospital behavior based on reputational concerns. This standard account, however, overlooks other important ways targeted transparency can influence hospital performance. This article presents a case study of disclosure laws designed to promote breastfeeding to illustrate how targeted transparency can influence hospitals independently of its effects on patients' choice of provider or hospitals' fear of losing business. We found that mandatory disclosure laws emboldened state regulators to take a more aggressive approach to enforcement of hospital regulations, empowered nurse managers to advocate more effectively within hospitals for changes in hospital policies, and enabled nurse managers to implement verifiable performance goals for clinical staff under their supervision. These findings suggest that the study of mandatory disclosure more generally--in areas such as financial regulation, environmental protection, food labeling, and workplace safety--would benefit by analyzing not only its influence on public awareness and its reputational effects but also how regulators use transparency laws and how managers within regulated entities employ the information that the laws provide.

Development of the breastfeeding quality improvement in hospitals learning collaborative in New York state.

Exclusive breastfeeding is a public health priority. A strong body of evidence links maternity care practices, based on the Ten Steps to Successful Breastfeeding, to increased breastfeeding initiation, duration and exclusivity. Despite having written breastfeeding policies, New York (NY) hospitals vary widely in reported maternity care practices and in prevalence rates of breastfeeding, especially exclusive breastfeeding, during the birth hospitalization. To improve hospital maternity care practices, breastfeeding support, and the percentage of infants exclusively breastfeeding, the NY State Department of Health developed the Breastfeeding Quality Improvement in Hospitals (BQIH) Learning Collaborative. The BQIH Learning Collaborative was the first to use the Institute for Health Care Improvement's Breakthrough Series methodology to specifically focus on increasing hospital breastfeeding support. The evidence-based maternity care practices from the Ten Steps to Successful Breastfeeding provided the basis for the Change Package and Data Measurement Plan. The present article describes the development of the BQIH Learning Collaborative. The engagement of breastfeeding experts, partners, and stakeholders in refining the Learning Collaborative design and content, in defining the strategies and interventions (Change Package) that drive hospital systems change, and in developing the Data Measurement Plan to assess progress in meeting the Learning Collaborative goals and hospital aims is illustrated. The BQIH Learning Collaborative is a model program that was implemented in a group of NY hospitals with plans to spread to additional hospitals in NY and across the country.

Improving hospital breastfeeding policies in New York State: development of the model hospital breastfeeding policy.

The public health importance of breastfeeding, especially exclusive breastfeeding, is gaining increased recognition. Despite a strong evidence base that key hospital maternity practices (Ten Steps to Successful Breastfeeding) impact breastfeeding initiation and exclusivity in the hospital and breastfeeding duration post-discharge, they are not widely implemented. In 2009, written hospital breastfeeding policies were collected from all New York State (NYS) hospitals providing maternity care services (n=139). A systematic assessment of the policies found that, on average, approximately half (19/32) the components required under NYS hospital regulations were included. Inclusion of each of the Ten Steps varied from 14% to 98%. An evidence-based Model Hospital Breastfeeding Policy was developed that included required components (based on NYS hospital regulations and legislation) and recommendations from expert groups such as the Academy of Breastfeeding Medicine, Baby Friendly USA, Inc., and the United States Breastfeeding Committee. Improved hospital breastfeeding policies are a critical first step in improving hospital maternity care to better promote, support, and protect breastfeeding. Additional efforts throughout health care, the workplace, and the broader community will be required to make breastfeeding the norm.

Improving maternity care practices in New York: answering the Surgeon General's Call to Action.

Hospitals providing maternity care influence breastfeeding mothers and infants during the critical, early postnatal period. Despite concerted public health efforts, there are persistent, large variations across New York State (NYS) hospitals in breastfeeding policies, maternity care, and infant feeding practices and in rates of breastfeeding initiation and exclusivity. An initiative addressing this issue is the Breastfeeding Quality Improvement in Hospitals (BQIH) Learning Collaborative, which was designed and implemented by the NYS Department of Health (NYSDOH). The BQIH Learning Collaborative, adapted from the Institute for Healthcare Improvement Breakthrough Series, embedded evidence-based maternity care best practices in a learning and quality improvement model. The Ten Steps to Successful Breastfeeding served as the backbone for improvement with the aims of increasing the percentages of infants fed any breastmilk and exclusively fed breastmilk while decreasing the percentage of breastfed infants supplemented with formula. Twelve hospitals were selected to participate based on their breastfeeding metrics: 10 of the hospitals were low performing, and two were high performing on these breastfeeding measures. During the 18-month BQIH Learning Collaborative, process improvement occurred for several measures, including breastfeeding within the first hour after birth, breastfeeding mother/infant rooming-in, and receipt of formula samples/discharge bags. NYSDOH plans to spread this Collaborative to all hospitals providing maternity care in NYS. Comprehensive breastfeeding initiatives will continue in NYS in the effort to ensure that all breastfeeding mothers receive optimal support from healthcare providers and hospitals with the goal of making breastfeeding the norm for infant nutrition during the first year of life.