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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Breastfeeding.

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Strategy. Quality Improvement

Approach. Implement quality improvement (QI) initiatives to create breastfeeding-friendly pediatric practices and resources

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Overview. Research indicates that QI initiatives can improve breastfeeding rates. Studies examined QI initiatives focused on assembling a multidisciplinary team of parents and community representatives to help hospitals achieve Baby-Friendly designation,[1] implementing the Ten Steps to Successful Breastfeeding through a statewide perinatal quality collaborative,[2] and improving the practice-wide standard of care and lactation support services in a pediatric practice to improve breastfeeding duration and exclusivity.[3]

Evidence. Moderate Evidence. Strategies with this rating are likely to work. These strategies have been tested more than once and results trend positive overall; however, further research is needed to confirm effects, especially with multiple population groups. These strategies also trend positive in combination with other strategies. (Clarifying Note: The WWFH database calls this "some evidence").

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source. (Read more about understanding evidence ratings).

Source. Peer-Reviewed Literature

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Health and Health Behaviors/Behavior Change. This strategy improves individuals' physical and mental health and their adoption of healthy behaviors (e.g., healthy eating, physical activity).
  • Policy. This strategy helps to promote decisions, laws, and regulations that promote public health practices and interventions.
  • Quality of Care. This strategy promotes the degree to which healthcare services meet established standards aimed at achieving optimal health outcomes.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Policy Development and Enforcement (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Community-Focused

Examples from the Field. Access descriptions of ESMs that use this strategy directly or intervention components that align with this strategy. You can use these ESMs to see how other Title V agencies are addressing the NPM.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies).

Quadrant 1:
Measuring Quantity of Effort ("What/how much did we do?")

PROCESS MEASURES:

  • Number of pediatric practices that initiated a QI project to improve breastfeeding support. (Measures practice engagement)
  • Number of staff members trained on breastfeeding best practices and QI methodology. (Assesses workforce development)
  • Number of patient and community representatives included in the QI team or advisory group. (Evaluates patient and community engagement)

OUTCOME MEASURES:

  • Total number of breastfeeding mothers and infants served by the pediatric practices participating in the QI initiative. (Captures population reach)
  • Number of new breastfeeding-friendly policies, procedures, or resources implemented as a result of the QI initiative. (Measures practice-level changes)
  • Number of breastfeeding mothers who received enhanced lactation support services through the QI initiative. (Assesses service delivery)

Quadrant 2:
Measuring Quality of Effort ("How well did we do it?")

PROCESS MEASURES:

  • Percent of QI team members who actively participated in all phases of the initiative, from planning to implementation and evaluation. (Measures team engagement)
  • Percent of breastfeeding mothers who received a comprehensive breastfeeding assessment and support plan at their pediatric visits. (Evaluates quality of care)
  • Percent of pediatric staff who demonstrated proficiency in breastfeeding support skills after completing QI-related training. (Assesses staff competency)

OUTCOME MEASURES:

  • Percent of breastfeeding mothers who reported high satisfaction with the breastfeeding support received from their pediatric practice. (Measures patient experience)
  • Percent of mothers who continued breastfeeding at 3, 6, and 12 months postpartum after the implementation of the QI initiative. (Captures breastfeeding duration)
  • Percent of infants who were exclusively breastfed at 3 and 6 months of age in the pediatric practices participating in the QI initiative. (Assesses breastfeeding exclusivity)

Quadrant 3:
Measuring Quantity of Effect ("Is anyone better off?")

PROCESS MEASURES:

  • Number of best practices or lessons learned shared with other pediatric practices to spread the QI initiative's successes. (Measures dissemination)
  • Number of collaborations formed with community organizations, such as WIC or lactation support groups, to enhance the QI initiative's impact. (Evaluates community partnerships)
  • Number of QI cycles completed to continuously monitor and improve breastfeeding support processes and outcomes. (Assesses continuous improvement)

OUTCOME MEASURES:

  • Number of breastfeeding challenges or complications that were proactively identified and addressed through the QI initiative's enhanced support services. (Captures preventive impact)
  • Number of pediatric practices that achieved Baby-Friendly designation or other breastfeeding-friendly recognition as a result of the QI initiative. (Measures practice recognition)
  • Number of infants who achieved optimal growth and development milestones while being breastfed, as promoted by the QI initiative. (Assesses child health outcomes)

Quadrant 4:
Measuring Quality of Effect ("How are they better off?")

PROCESS MEASURES:

  • - Percent of underserved or high-risk populations that were actively engaged and represented in the QI initiative's planning and implementation. (Measures health equity focus)
  • - Percent of QI initiative's resources and materials that were culturally and linguistically tailored to the diverse patient populations served. (Evaluates cultural responsiveness)
  • - Percent of pediatric practices participating in the QI initiative that are located in areas with historically low breastfeeding rates or limited access to lactation support. (Assesses geographic equity)

OUTCOME MEASURES:

  • - Percent reduction in breastfeeding disparities among racial, ethnic, or socioeconomic groups served by the pediatric practices participating in the QI initiative. (Measures equity impact)
  • - Percent of mothers from disadvantaged communities who reported increased breastfeeding knowledge, confidence, and social support as a result of the QI initiative. (Captures empowerment)
  • - Percent increase in breastfeeding initiation and duration rates at the community level, particularly in areas served by the pediatric practices participating in the QI initiative. (Assesses population health impact)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

References

1 Feldman-Winter, L., Ustianov, J., Anastasio, J., Butts-Dion, S., Heinrich, P., Merewood, A., ... & Homer, C. J. (2017). Best fed beginnings: a nationwide quality improvement initiative to increase breastfeeding. Pediatrics, 140(1).

2 Ware, J. L., Schetzina, K. E., Morad, A., Barker, B., Scott, T. A., & Grubb, P. H. (2018). A statewide quality improvement collaborative to increase breastfeeding rates in Tennessee. Breastfeeding Medicine, 13(4), 292-300.

3 Imboden, A., & Lawson, R. (2021). Improving breastfeeding duration through creation of a breastfeeding-friendly pediatric practice. Journal of the American Association of Nurse Practitioners, 33(12), 1273-1281.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.