Breastfeeding Kickstart

Barbara L. Philipp, MD is Professor of Pediatrics at Boston University School of Medicine, and a Fellow of the American Academy of Pediatrics and the Academy of Breastfeeding Medicine. She is a pediatrician who believes passionately in the importance of breastfeeding and sees how hard it can be for new mothers while working in the MotherBaby Unit at Boston Medical Center (BMC).    

In 1999, refusing to accept the comment that "poor women don’t want to breastfeed,” she helped lead BMC to Baby-Friendly designation, an international award recognizing breastfeeding excellence. BMC became the first hospital in Massachusetts and the 22nd in the nation with the award. She works now to help other hospitals achieve the award and with women to help them be successful with breastfeeding.  

Dr. Philipp is a 2008 recipient of a St. Lawrence University Alumni Citation for her work in the field of maternal and child health.

Breastfeeding provides infants with the normal first food and mothers with the normal way of feeding. Are you thinking, I agree, so what's the problem? Unfortunately, breastfeeding rates in the United States are alarmingly low, particularly among women of color. The Baby-Friendly Hospital Initiative was started to address this problem. Baby-Friendly is a WHO/UNICEF designation recognizing breastfeeding excellence. Baby-Friendly is based on the Ten Steps to Successful Breastfeeding. The Breastfeeding Kickstart Project will work to increase breastfeeding rates among all babies by increasing the number babies born in Baby-Friendly hospitals in the United States. Currently 100% of babies born in Sweden, Scotland and Cuba are born in hospitals with the Baby-Friendly designation. In the US only 28% of babies are born in such hospitals. This project will assist 10 maternity hospitals in achieving Baby-Friendly designation. The benefits of breastfeeding will last a lifetime for these babies and their mothers.

Breastfeeding rates in the USA are low, with marked disparity gaps. The American Academy of Pediatrics recommends exclusive breastfeeding for the first six months of life and continuing breastfeeding until a year of age or longer per the mother's wishes. However, the 2019 CDC Breastfeeding Report Card for US Breastfeeding Rates (%) by Race and Ethnicity show how far we are from meeting those goals:                                                
                                Exclusive 6 months / Any breast milk  at 12 months         National Average       25.4                      /    36.2

  Asian                       31.8                     /    51.6

  Non Hisp White        29.1                     /    39.6

  Hispanic                  20.4                     /    22.1 

  Non Hisp Black        20.7                     /     27.1

The maternity hospital experience is key to breastfeeding success as breastfeeding prolactin receptors, milk supply, and the baby's suck are set up in the first days and first week.  Currently, most maternity hospitals fail to practice evidence-based care: they routinely separate mothers and babies, fail to provide staff any education on lactation topics, and accept formula and formula products for free from the formula industry. The problem I am trying to solve is to improve maternity care when it comes to practices that affect breastfeeding. If a mother doesn't get breastfeeding started, she can't keep it going.   

Breastfeeding Kickstart will provide assistance to ten maternity hospitals to help them achieve WHO/UNICEF Baby-Friendly designation. The keystones of the Baby-Friendly Hospital Initiative are: 1) the hospital works to keep mothers and babies together, 2) educates maternity staff in lactation medicine, and 3) pays a fair market value for infant formula and formula products.  The journey involves advancing along a Baby-Friendly USA 4D Pathway: D1 - application process, D2 - form a task force, write an infant feeding policy and develop plans for teaching, D3 - make it happen (toughest part), D4 - on site assessment. Baby-Friendly hospitals have been shown, repeatedly, to have increased breastfeeding rates. Boston Medical Center has been Baby-Friendly for 20 years. BMC's breastfeeding initiation rate increased from 43% to 90% and our exclusive breastfeeding rate prior to discharge increased 6-fold. Boston Medical Center, a safety net hospital, cares for mostly poor and minority women, groups that are associated with low breastfeeding rates. We have shown the problem with our previously low breastfeeding rates was the hospital, not the families. We will offer hands on technical expertise and trainings to help hospitals advance along the Baby-Friendly Pathway. Support for this project recognizes the importance of breastfeeding.

This work  will serve all mothers and their babies born at these hospitals.  The hospitals will be selected in a random fashion, pulling from a pool of interested facilities. With the connections I have we will be able to reach out to a variety of states - Massachusetts, New Hampshire, Vermont, Louisiana, Michigan, Maine, Missouri, West Virginia and other interested states. The offer of technical assistance will be greatly appreciated by hospitals as this is a difficult award to achieve. Of note, the care offered at a Baby-Friendly hospital is evidence-based care for all mothers, those who wish to breastfeed and those who wish to formula feed. For formula feeding mothers the care includes: skin to skin holding in the first hour, rooming in safely so mother can get to know her baby and learn about feeding cues, appropriate volumes of infant formula to feed on each day using a paced feeding technique (so baby does not have an elevated risk of obesity starting in the first week), information on safe sleep including pacifier use, and info on how to safely prepare formula. Whichever way the mother wants to feed her baby - she will receive the best care. 

Q. Who is likely to breastfeed in the United States of America?

A. Rich, white, married, older and educated women.

Q. Describe maternal risks of less breastfeeding.

A: Less breastfeeding increases the mother's risk of cancer (breast, ovarian and endometrial), high blood pressure, heart attacks/strokes, and type two diabetes.

Q. Describe risks of less breastfeeding for children.

A: Less breastfeeding increases the baby / child's risk sudden infant death syndrome and necrotizing enterocolitis, obesity, pneumonia, otitis media, leukemia and lymphoma, and type two diabetes

ALL babies and all mothers deserve the best start.

In 1995 I was appalled at the horrible breastfeeding rates at Boston Medical Center: healthy babies were lined up in the nursery (separated from their mothers) and the formula sales representatives roamed the halls with their free stuff.

In response, from 1997-1999, I co-chaired the BMC Baby-Friendly Task Force, which successfully led the hospital to Baby-Friendly designation. I was a member of the teams that helped the hospital achieve re-designation in 2007 and 2014 and am currently a co-chair of the hospital’s Baby-Friendly Task Force. BMC received Baby-Friendly redesignation again in September 2019. This was difficult, but we did it, and our breastfeeding rates soared. If BMC, a safety net hospital caring for women who traditionally have the lowest breastfeeding rates in the country, could do this, then others could do it as well and that became my focus, to help other hospitals achieve the designation.

With financial support from the W.K.Kellogg Foundation (that recently ended), I convened 25 MotherBaby Summits in 5 different states to help maternity leaders understand breastfeeding and Baby-Friendly. Some Summits attracted 230 maternity leaders. In 1999, BMC was the only Massachusetts' Baby-Friendly hospital, now there are 18. But there is more work to be done. 

Breastfeeding happens or doesn't happen in the first week of life. The mother's prolactin receptors in her breast tissue need to be set up, her system needs to be asked to make the milk repeatedly, and the baby needs to learn to suck a certain way.

I was always a pediatrician who "supported breastfeeding." At least I said I did. However, I had never received any education on any lactation topic in all my years of pediatric training and I was a resident at a hospital with horrible breastfeeding rates. The babies were all in the nursery all the time and were all being fed formula right from the minute they were born. Those mothers and babies didn't have a chance at breastfeeding success.

But - what made me angry and  passionate about the topic - was when I saw what the formula industry was doing to sabotage the breastfeeding relationship in the first week - including free food and gifts for staff, free formula and bottles, and misleading educational displays  They gave cases of formula to hospitals for free (all hospitals at the time).. It was unethical; the relationship needed to be exposed and changed.

I am a physician who helped my hospital get the Baby-Friendly award in 1999 and I have worked in a Baby-Friendly hospital for twenty years.

I have helped numerous other hospitals get to Baby-Friendly. I have run MotherBaby Summits in MA, Penn, WV, Louisiana, and Missouri to help educate maternity staff about breastfeeding and Baby-Friendly. I have conducted mock surveys for hospitals prior to their actual Baby-Friendly site assessment.

I have published numerous research articles and have written extensively about breastfeeding and Baby-Friendly. I created an on-line course, Bella Breastfeeding: Provider Training, to train physicians on the topic. In just over two years the course has been taken by over 1850 providers. I created Bella Prenatal Education Videos on You Tube in English, Spanish and Portuguese. These can be used by hospitals on the Baby-Friendly Pathway for Step 3 Prenatal Education for pregnant women. I am the author of the book, The Breastfeeding Blueprint: How to Get Started and Keep it Flowing for a Year, available on Amazon.

I work with young doctors in training and medical students at Boston Medical Center and teach them about breastfeeding throughout the year.

I know a lot about breastfeeding.

I am passionate about this topic.

I am a change agent.

Finally, I am a physician. Physicians hold the power in hospital, and physicians only like to learn from physicians (I hate typing that statement, but it is true).

My entire career has been a big fight. I fought to get our Mother Baby Unit to change from all the babies going to the nursery for hours, to mothers and babies staying together. I fought to get everyone of the doctors and nurses in the BMC maternity unit to complete breastfeeding education --- three hours for doctors, 20 hours for nurses. I fought to delay the baby's bath so the baby could stay with the mother. I fought to get pasteurized human donor milk into our hospital. But, the biggest fight was to expose what was going on with the infant formula industry in our hospital and get BMC hospital administration to agree to pay fair market value for formula and formula products. We did it and became the first hospital in MA to achieve Baby-Friendly. To be clear, we need infant formula and we need the best infant formula that can be made. What I object to is the marketing that the formula industry does and the money the industry makes. Infant formula is a 70 billion dollar a year industry. It is very hard to compete with them - let alone find any funding for breastfeeding work.

In regards to paying for the infant formula and formula products in our hospital, the first proposal to the hospital administration was unanimously rejected. As the leader of the Task Force, I refused to accept that. I organized a team that gathered data from each unit in the hospital to prove how much formula we were using and how much it would actually cost. The formula representative was quoting a $100,000 a year figure; our data showed $25,000 a year. I gathered the support of the President of the Hospital, Chairman of the Department of Pediatrics, the Chairman of the Department of OB/GYN, the Chairman of the Department of Family Medicine and the Hospital Chief Medical Officer. This was a difficult ask because Boston Medical Center is not a wealthy hospital. The President of the Hospital said it best, we need to do this because it is the right thing to do and it meets BMC's mission of "Exceptional Care Without Exception." The second proposal was approved which opened the door for BMC's official Baby-Friendly designation.

This prize will support the work I am doing and will be doing for others. I am an employee of Boston University School of Medicine and work at Boston Medical Center. Both are non-profit organizations. The administrative help to process grant money would come from the financial department that serves both of these institutions. I am not a big group or a big organization, I am a passionate individual looking for support.

Boston Medical Center became the first Baby-Friendly designated hospital in 1999 and the 22nd in the nation. To achieve this award we had to redesign the maternity care we offered. With the new changes, mothers and babies stayed together - we went to them, not the baby to us (in the Nursery). Staff received education on lactation medicine (at first quite reluctantly). Nurses received 20 hours of education, every doctor and midwife and NP received three hours. The infant formula salesmen were kicked off the unit - and the hospital paid fair market value for formula and formula products.

Hospitals are conservative and tend to do like everyone else is doing. When we started this work in 1997, we were practicing maternity care like all the other hospitals in the state (and the nation). To get the hospital administrators to agree to these changes took a lot of education and trust. There was concern mothers would not like the new model of care. There was concern mothers would not want to breastfeed. Now, twenty years later, we can report the opposite. Delivery volume increased from 1600 births per year to the current 2850 births per years. Breastfeeding rates soared.

We have learned a lot over the twenty years - especially how great the care is that we offer now. I am passionate about helping other hospitals learn about this and help them change. The change will last for years and years.

What is my theory of change? Interesting question. When I first started working on my idea, back in 1997, I didn't know much about breastfeeding nor Baby-Friendly. My first task was to read and study and listen to others who knew more than I did on both topics. I attended a 5-day conference on breastfeeding in Tallahassee, Florida and could not believe the statistics and information I was learning that I had never heard before. The more I learned, the more appalled and angry I became at what we were doing. I didn't really know what I was doing at all - but we adopted the idea that we would not accept no for an answer - that we were smart (our Task Force members) and we would figure out a way around any road block. Getting PEOPLE to change was the hardest part. I divided people (often nurses) into three groups - 1) totally got the issue and the plan 2) were skeptical but willing to learn and 3) would never change their ways ever and simply had to eventually retire (which many did). We championed group 1 and taught group 2 like crazy. Group 3 we ignored. At times we needed to use a sledge hammer to move things along - not the best approach but was needed at times.

Now I am familiar with Quality Improvement Strategies like Plan - Do - Study - Act (PDSAs) and have used that approach (for example when we started donor milk on the Mother Baby Unit). This is a gentler approach that works much better but it took me a while to learn it.

Change needs a champion. Change needs someone who thinks about the issue all the time - goes to bed thinking about it - wakes up thinking about it. The champion does much of the behind the scenes work that needs to be done to move a project along. I was the champion for BMC. Working with other hospitals it seems there is a champion making things happen -- often they just need some help.

Let's say this project helps 10 hospitals get the Baby-Friendly award. Let's say each hospital has a delivery volume of 1500 babies (and 1500 mothers). In the first year this work will impact the health of 30,000 mothers and babies; in 5 years it will impact the health of 150,000 mothers and babies.

The goal of this project is to help 10 US maternity hospitals get the Baby Friendly award. Each hospital will receive help to get on and move along the Baby-Friendly USA Pathway. I will offer monthly zoom meetings, expert assistance for how to move along Pathways, and mock site visits prior to the real site visit. Help will include:

1) Help on how to form a Task Force, appropriate members, appropriate meeting times

2) Assistance in writing an Infant Feeding Policy that will meet Baby-Friendly criteria

3) Education regarding how to offer immediate and uninterrupted skin to skin holding in the first hour of life in the Labor And Delivery Unit

4) Assistance in how to convert to rooming-in where the healthy baby stays with the healthy mother (both 3 and 4 need written policies that meet criteria)

5) Assistance in developing plans for staff education on lactation medicine. Every doctor needs three hours; every nurse 20 hours. This project includes updating the online-course Bella Breastfeeding: Provider Training. The beauty of this course is that it is free to hospitals.

6) Expertise in meeting the prenatal education requirement - this project will include the development of 4 more prenatal education videos in French, Haitian Creole, Vietnamese and Arabic.

7) Expert assistance in how to collect data on rooming in rates, skin to skin rates, breastfeeding rates

8) Review of written materials required by Baby-Friendly USA.

9) A Mock Site Visit prior to the real Baby-Friendly USA site visit. 

The biggest barrier for me is finding money to pay for my time. I know what to do, I know how to do it, but I need to find funding to cover my time.

A pediatrician in the Department of Pediatrics at Boston Medical Center is paid from a variety of sources - working clinical sessions being the most common source. Each 4-hour session in the primary care clinic seeing children for check ups or illnesses counts at 10%. Working as an attending in the Mother Baby unit is another source. Teaching medical students or pediatric residents also counts. THese obligations take 

A prize like this would allow me to ease up on some of my clinical load to focus on this project. I would also be able to hire some fellow experts to offer technical assistance to hospitals.

There are going to be other barriers. Hospitals who are part of Breastfeeding Kickstart will need to make a lot of changes to get the award. They will need to find leadership, form a Task Force, rip up old policies and write new policies, start extensive training for staff, and convince the hospital administration to pay for formula and formula products. My team will have extensive experience in doing this and will be able to help. Over the years what we have found are the same barriers at each hospital - so we are ready to tackle them.

I work with the MA Breastfeeding Coalition, Vital Village, and Baby Cafe USA. I work to support the organizations. I am a Co-Chair of the Massachusetts Breastfeeding Coalition. All of this work is done on a volunteer basis.

This prize would support my time to do the work described. I would continue to work half-time in the hospital maternity unit caring for mothers and babies. I feel this is important so I know the struggles in the workplace that others are up against. This prize would allow me to devote the other half towards this project: 1) Technical assistance for 10 hospitals 2) Revision of an online course that I wrote, Bella Breastfeeding: Provider Training (this allows the hospital to meet the provider education requirement at no cost) and 3) Creation of 4 videos in French, Haitian Creole, Vietnamese and Arabic (videos already exist in English, Spanish and Portuguese - this allows the hospital to easily meet the Step 3 requirement). This prize would also allow for funding for two other experts that I would need to hire.

I will continue to work on the front lines for 50% of my time, as a pediatrician at Boston Medical Center. This prize would support some of the rest of my time.

I was able to do the work described to date due to some funding from the W.K.Kellogg Foundation which has expired.  This money supported my time to be on the BMC Baby-Friendly Task Force, keep up with our Baby-Friendly designation, and run some Mother Baby Summits.  

My salary is $200,000.

Fringe benefits run 20% so $40,000.

I need to raise half of this so $120,000. The rest of the prize will go to hire to other experts who will work with me to help the hospitals. I currently work closely with Mary Foley who is a Nurse and Lactation Consultant at a neighboring hospital in Massachusetts. She helped her hospital get to the Baby-Friendly award about 10 years ago. She knows Baby-Friendly. Another expert is Kim Pena, the Nurse Manager for Maternity at St. Luke's Hospital in New Bedford, MA. She recently championed the cause at St. Luke;s on their Baby-Friendly journey. I would pay each of them $10,000 a year for their efforts.

Per year

B Philipp salary and fringe $120,000

M Foley consulting fee $10,000

K Pena consulting fee $10,000

This may be modified slightly to allow for some monies ($10,000) to give to hospitals to help with Baby-Friendly feeds.

As I have mentioned before in this application, finding funding for breastfeeding is difficult. The need is great and many simply do not understand the area. This Prize seems to be looking for innovators and change agents to support. That is me!

I do not have a big organization behind me other than I am a pediatrician at Boston Medical Center that has been extremely supportive of the breastfeeding work - as it fits the hospital's goal of Exceptional Care Without Exception. However, to do this I have had to find a lot of my own funding.

If we can do this here, at Boston Medical Center, a hospital with significant social challenges (poverty, teenage pregnancy, homelessness, substance use disorder, domestic violence) then other hospitals can do it as well with help.

The formula industry makes $70 billion a year - and puts 10-15% of that into marketing. The breastfeeding industry certainly is not as organized and has minimal funds to put into marketing. Partnering with marketing,media and exposure experts would be a first.

I would like to partner with other hospitals.

I would like to partner with social media savvy groups perhaps to run some Ad Campaigns to get the work out that breast milk and infant formula are not the same at all, not even close.