Policies and practices related to breastfeeding in Massachusetts: Hospital implementation of the ten steps to successful breastfeeding

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.