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Advancing Women’s Health:

Health Plans’

Innovative

Programs in

Breastfeeding

Promotion

July 2001

Survey Results & Case Studies

This report was supported by a contract (00T002138) from the Office on Women’s

Health of the Office of the Secretary, U.S. Department of Health and Human Services.

Project Officer: Suzanne G. Haynes, PhD

Assistant Project Officer: Ekaterini Malliou, MPH

Advancing

Women’s Health:

Health Plans’

Innovative

Programs in

Breastfeeding

Promotion

Authors:

American Association of Health Plans

Carmella Bocchino, RN, MBA

Najm Hodge-Bethea

Barbara Lardy, MPH

Susan Messina, MSS, MLSP

Juli Pencek

Office of Women’s Health, Office of the Secretary,

U.S. Department of Health and Human Services

Suzanne G. Haynes, PhD

Ekaterini K. Malliou, MPH
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Table of Contents

Acknowledgments ................................................................. 7

Preface .............................................................................. 9

A Message from the Surgeon General, U.S. Public Health Service ..... 11

Executive Summary ............................................................. 13

Study Methodology and Findings ............................................. 17

Overview: Focus on Breastfeeding............................................ 21

Case Study I—Health Net, Inc.:

Strategic Action Plan for the Promotion of Breastfeeding................. 27

Case Study II—HealthPartners:

Breastfeeding & Parent Support Center ...................................... 33

Case Study III—Independent Health:

Prenatal Case Management ................................................... 39

Case Study IV—Kaiser Health Plan of Georgia:

The Maternal/Child Health Lactation Program.............................. 45

Case Study V—Kaiser Permanente Northwest:

The Mother-Baby Program ..................................................... 51

Case Study VI—Kaiser Permanente Southern California:

Lactation Promotion ............................................................ 57

Case Study VII—Keystone Health Plan East:

Baby BluePrints/Baby FootSteps .............................................. 65

Case Study VIII—UCare Minnesota:

Breastfeeding Promotion Program ........................................... 71

Health Plans, as Employers, Supporting Breastfeeding Mothers

Who Return to Work ............................................................. 77

References ....................................................................... 83

Appendix A: AAHP’s Women’s Health Subcommittee ...................... 88

Appendix B: Breastfeeding Monograph Review Committee .............. 89
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Acknowledgments

The American Association of Health Plans (AAHP) would like to acknowledge

the following individuals and organizations for their contributions:

AAHP’s Breastfeeding Monograph Review Committee

✹ Delores F. Baker, MD, The Wellness Plan

✹ Julie Gazmararian, MPH, PhD, USQA Center for Health Care Research

✹ Richard Kopher, MD, HealthPartners

✹ Tracy Lieu, MD, MPH, Harvard Pilgrim Health Care

✹ Leith Mullaly, RNC, MSN, IBCLC, Association of Women’s Health, Obstetric

and Neonatal Nurses

✹ Denise Sofka, MPH, RD, Maternal Child Health Bureau, Health Services and

Resources Administration, U.S. Department of Health and Human Services

Health Plans and Their Representatives

✹ Aetna, Inc.—Barbara Pelletier and Alice Guilbert

✹ Health Net—Jude Sell-Gutowski, RN, MS and Effie Hubbard Ruggles

✹ HealthPartners—Teresa Kovarik, MD, and Molly Tatting

✹ Humana Inc.—Janet Watchmaker and Elona DeGooyer

✹ Independent Health—Janet Stoeckl, RNC, CCM

✹ Kaiser Permanente Northwest—April Henry, Deborah Myers, Jean Rystrom,

and Carol Tracy, RNC

✹ Kaiser Permanente of Southern California—David Braun, MD, Denise Parker,

Lois Watts, Raquel Korn, Annette Broadhurst, Terry Ma-Ares, Mei-Ling

Schwartz, Chris Wade, MD, Deanna Ritchie, Ursela Doidic, Judy Collier,

and Ashley Green, MD

✹ Kaiser Health Plan of Georgia—Ann Weathersby, MSN, CNM and Jamie Ray,

RN, CCE, IBCLC

✹ Keystone Health Plan East—Cathy Dratman, MD, and Margaret Ryan-Cook,

RN

✹ Physicians Health Plan of Northern Indiana, Inc.—Jana Smith

✹ UCare Minnesota—Craig Christianson, MD, Ghita Worcester, Kathy Lamp,

Carol Berg, Margery Petersen
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Preface

Women represent more than 51% of the U.S. population, 60% of the labor force,

and make most of the health care decisions for themselves and their families. Until

recently, medicine has been slow to respond to the special health care needs of

women. Today, however, health plans are doing exemplary work in meeting women’s

needs through a wide variety of programs, interventions, and partnerships aimed at

addressing critical women’s health issues.

The American Association of Health Plans (AAHP) has been proud to focus on

these efforts through the Advancing Women’s Health monograph series. Previous

topics in the series have included high-risk pregnancy, breast cancer, mid-life issues,

osteoporosis, depression, and domestic violence. Each report in the series highlights

excellent care models offered by member plans and provides a glimpse into how

health plans systematically and continually organize, coordinate, and track health

services in order to improve outcomes.

This latest monograph focuses on the important topic of breastfeeding. Although

breast milk provides infants with the ideal form of nutrition and while breastfeeding

confers major health benefits on mothers and babies, too few American women

choose to breastfeed. Those that do can encounter early challenges that make

continuation difficult unless they receive appropriate lactation counseling and

support. Health plans have a vital role to play in increasing the number of women

who successfully breastfeed their babies. As the case studies in this monograph

compellingly demonstrate, health plans are promoting breastfeeding through a range

of educational, support, and case management programs.

The case studies included in this report deserve to be widely read by consumers,

policymakers, and health plan staff. They will help consumers better understand

how health plans can support the decision to breastfeed. They will help policymakers

appreciate the unique strengths that managed care brings to the ongoing challenge

of increasing the percentage of women who initiate and maintain breastfeeding.

And within the community of health plans, they will provide new tools and new

inspirations for professionals dedicated to assisting mothers and babies in getting

the best possible start.

Karen Ignagni

President and Chief Executive Officer
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A Message from the Surgeon General,

U.S. Public Health Service

Health plans have an instrumental role to play in promoting breastfeeding to

American families. The HHS Blueprint for Action on Breastfeeding, which was

released on October 30, 2000, recommends that infants should be exclusively

breastfed during the first four to six months, preferably for a full six months, and

ideally through the first year of life. It also recognizes the contribution of the health

care system in improving breastfeeding and recommends that the health care system

needs to:

✹ Train health care professionals who provide maternal and child care on the

basics of lactation, breastfeeding counseling, and lactation management

during internship, residency, in-service training, and continuing education.

✹ Ensure that breastfeeding mothers have access to comprehensive, up-to-date,

and culturally tailored lactation services provided by trained physicians,

nurses, lactation consultants, and nutritionists/dieticians.

✹ Establish hospital and maternity center practices that promote breastfeeding

such as the “Ten Steps to Successful Breastfeeding.”

✹ Develop breastfeeding education for women, their partners, and other

significant family members during the prenatal and postnatal visits.

The health care system can make a significant difference in the breastfeeding

experience of mothers. Health plans can influence both families and health care

providers through targeted educational interventions promoting breastfeeding. In

addition, they can offer breastfeeding support services before, during, and after

birth. Specifically, health plans can support breastfeeding mothers during the critical

first days and weeks postpartum by offering all mothers access to lactation

management services provided by trained physicians, nurses, lactation specialists,

and peer counselors or other trained healthcare providers. It is also important that

all healthcare providers who interact with women or infants are knowledgeable

about the basics of lactation and the role their specialty plays in breastfeeding. For

example, providers of maternal and child health care have a special role in the

promotion of breastfeeding during the prenatal and postnatal periods. They must be

knowledgeable, skillful and continuously educated in counseling women about

breastfeeding and lactation.

To this end, culturally appropriate training for breastfeeding should be integrated

into the curricula of health profession schools, with attention to barriers that could

interfere with breastfeeding. Nonsupportive hospital experiences and lack of support

from healthcare providers have been identified as barriers to breastfeeding, especially

among African American women. Therefore, maternity care and newborn facilities

must adopt practices conducive to proper lactation even when in-hospital maternity

care is of short duration.

Cost savings is an obvious concern for most health plans and their enrollees.

Breastfeeding can provide economic benefits to individual families and health plans.

For families who choose breastfeeding, costs of infant feeding are substantially

reduced. Even after accounting for the costs of breast pump equipment and additional

food required by the nursing mother, families could save several hundred dollars

over the course of the infant’s first year. Because breastfed babies are in general
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healthier than non-breastfed babies, they require fewer sick care visits, prescriptions,

and hospitalizations, which lead to reduced health care expenditures. Employers

also benefit since breastfed infants are sick less often; therefore maternal absenteeism

from work is significantly lower in companies with established lactation programs.

This monograph highlights the outstanding programs of eight health plans

that promote breastfeeding among enrollees, and three health plans that have

demonstrated their commitment to breastfeeding promotion through programs for

their own employees. Based on the experiences of these health plans, the lessons

learned may be helpful for other managed care organizations interested in promoting

breastfeeding. Health plans, including health maintenance organizations (HMOs),

preferred provider organizations (PPOs), point-of-service (POS) plans, and all other

health plan types, share a common focus on disease prevention and health promotion.

Breastfeeding is part of this focus since it promotes infant and maternal health, and

decreases the frequency of doctor visits, hospitalizations, and medication utilization.

The HHS Blueprint for Action on Breastfeeding calls for an immediate response to

the major public health challenge of improving breastfeeding rates. Health plans

are essential partners for us to achieve this goal.

David Satcher, MD, PhD

Surgeon General

U.S. Public Health Service

U.S. Department of Health and Human Services
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Executive Summary

This publication summarizes key findings from AAHP’s assessment of eight

health plans that have implemented innovative programs to promote breastfeeding

among enrollees. It also highlights three health plans that have demonstrated their

commitment to breastfeeding promotion through programs for their own employees.

Breastfeeding is the optimal way to feed infants. Breastfeeding promotes infant

and maternal health, decreases the frequency of doctor visits, hospitalizations, and

medication utilization, and thereby lowers medical costs. As a result, the decision

to breastfeed is of significant importance to the newborn child, the mother, and the

health care system.

Healthy People 2010, the health agenda for the Nation set every 10 years,

establishes objectives for improving breastfeeding rates among all racial and ethnic

groups in America: 50% of mothers to breastfeed exclusively for six months and

25% of those mothers to continue nursing through the end of the baby’s first year of

life. According to the HHS Blueprint for Action on Breastfeeding, a comprehensive

framework to promote breastfeeding released by the Surgeon General in October

2000, significant steps must be taken to increase breastfeeding rates and to close

the wide racial and ethnic gaps in breastfeeding. The HHS Blueprint for Action

states that the Healthy People 2010 goals can only be achieved through

comprehensive support for breastfeeding in the family, community, workplace, health

care sector, and overall society.

Health plans have key roles to play in encouraging women and their families to

initiate and maintain breastfeeding. Broadly, opportunities for support include

provider education, prenatal patient education and counseling, postpartum inpatient

and outpatient lactation support, home care, and assistance with back-to-work issues.

The health plans highlighted in this report each provide a unique array of

breastfeeding education and promotion services.

Promising Strategies

The following eight organizations participated in AAHP’s identification of

promising strategies for promoting breastfeeding among enrollees.

✹ Health Net, Inc. has developed a Strategic Action Plan for the Promotion of

Breastfeeding to address the decrease in breastfeeding prevalence among the

Medicaid populations served by the health plan. The strategy is comprised of

specific action plans to address breastfeeding through provider education,

member education, provider network management services, public health

coordination, and corporate commitment.

✹ HealthPartners provides comprehensive services, including prenatal

education and support, discharge planning, postpartum lactation support, and

assistance with rental or purchase of breast pump equipment, through its

Breastfeeding & Parent Support Center.

✹ Independent Health has a Prenatal Case Management Program that targets

members who are identified as high risk for pregnancy complications. Home

visits by nurses form the centerpiece of this program. Breastfeeding is

promoted in a variety of ways, including prenatal education, postpartum visits,

and breast pump rental.
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✹ Kaiser Health Plan of Georgia promotes breastfeeding through a series of

educational components, including a specially-produced video, “Celebrate the

Miracle,” educational handouts, no-cost breastfeeding classes, continuing

education for providers, and postpartum lactation support.

✹ Kaiser Permanente Northwest has a Mother-Baby Program that incorporates

prenatal education, inpatient lactation support, and outpatient lactation

consultation services. In addition, through staff education efforts, Kaiser

Permanente Northwest ensures that the health plan’s strong commitment to

breastfeeding promotion is demonstrated consistently.

✹ Kaiser Permanente of Southern California has a comprehensive program

that includes prenatal education, inpatient lactation support, postpartum

outpatient support, a breastfeeding information line, breast pump rental

services, and provider education. The health plan has several Medical Centers,

each of which serves a unique racial/ethnic membership composition.

Educational programs, classes, and services are developed to meet the specific

needs of the community.

✹ Keystone Health Plan East’s Baby BluePrints (or Baby Footsteps as the

program is called outside of Pennsylvania), is a comprehensive perinatal

program including prenatal risk assessment, information dissemination, case

management, and postpartum services for at-risk mothers and newborns.

✹ UCare Minnesota has a Breastfeeding Promotion Program featuring strong

community partnerships with state and local public health agencies and

educational components targeted to all Minnesota residents, with particular

emphasis on pregnant Medicaid enrollees and their families. UCare has also

provided funding for a breastfeeding intervention targeted specifically to the

Hmong population in Minnesota.

Programs for Health Plan Employees

While health plans are most often recognized for their role in promoting enrollee

health, health plans are also employers, and as such have a tremendous opportunity

to make a difference in the lives of the women they employ. The following three

organizations illustrate the ways some health plans are promoting breastfeeding

among their own employees:

✹ Aetna Inc.’s Corporate Lactation Program encompasses services prior to

delivery, during maternity leave, and upon return to work. The program

includes breastfeeding classes, unlimited consultations with a lactation

consultant, access to an electric breast pump in private rooms at the worksite,

a personal accessory carrying case with bottles, and a refrigeration

compartment to store breast milk safely.

✹ Humana, Inc.’s NursingMoms program encourages pregnant employees to

enroll in either on-site or community breastfeeding classes. Women are given

incentives for their participation, including a $25.00 coupon toward the

purchase of a breastfeeding kit and/or insulated carrying bag from Medela®.

These kits hook up to the hospital-quality Medela® double breast pumps

provided in the lactation rooms provided at the workplace.
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✹ Physicians Health Plan of Northern Indiana, Inc. provides support to

breastfeeding mothers through provision of the “mother’s room,” with a lock

for privacy, a comfortable recliner, and an electric breast pump. Managers

work with employees to schedule pumping sessions during the day.

Attachments for the breast pump and coolers for storing expressed milk are

available to employees for purchase at cost.

Overall Lessons Learned

Based on the experiences of the health plans described in this report, the following

lessons may be helpful for other managed care organizations interested in promoting

breastfeeding:

✹ Find a champion—obtain senior management support, using the science

proving breastfeeding is optimal;

✹ Build the business case for a return on investment, using data that

demonstrates patient satisfaction and significant cost in medical saving;

✹ Incorporate consistent pro-breastfeeding messages throughout all prenatal

education and counseling sessions;

✹ Build a culture that promotes breastfeeding as the best infant feeding choice;

✹ Sell the program to providers in the network—convince them of the value of

the program;

✹ Provide continuing education opportunities to obstetricians/gynecologists,

nurses, nurse-midwives, and other personnel who routinely are in contact with

pregnant or lactating women;

✹ Work with hospitals in the network to implement practices that promote

breastfeeding, including putting the baby to the breast immediately in the

delivery room, rooming-in, and providing access to inpatient lactation

consultation;

✹ Utilize certified lactation consultants;

✹ Establish a network of community resources for referral;

✹ Establish postpartum support procedures, including routine nurse follow-up

calls, access to lactation consultants, and/or a telephone advice line;

✹ Offer high quality breast pumps at cost or partial reimbursement for purchase

or rental;

✹ Consider targeting special efforts to racial and ethnic minorities, low-income

women, teenagers, and women with high-risk pregnancies; and

✹ Provide culturally appropriate educational materials translated in the

languages of the patients.
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Study Methodology and Findings

Background

In 1996, AAHP convened representatives from member health plans, including

primary and specialty care medical providers, health services researchers, quality

improvement professionals, health educators, and health policy experts to guide

the work of the association in the area of women’s health and managed care. This

group became the Women’s Health Subcommittee (see Appendix A). For this

monograph on breastfeeding, a special Review Committee was formed that included

a member of the Subcommittee as well as five additional members representing

health plans, breastfeeding experts, health services researchers, and government

agencies (see Appendix B).

Review of the Process

The practices that are showcased in this monograph represent only a fraction of

the initiatives that health plans have developed to improve women’s health. AAHP’s

study of “best practices” in women’s health highlighted a sample of plans that

responded to AAHP’s request for model programs. Overall, the process included

the following steps:

✹ Inviting AAHP’s entire membership to submit information on their

breastfeeding promotion programs, for both health plan members and health

plan employees;

✹ Screening the submissions for key elements such as program title, program

components, goals, evaluation, and results to date;

✹ Reviewing the screened group of submissions using 12 criteria, including

goals/objectives, innovative program qualities, quality of program evaluation,

and sustainability;

✹ Selecting eight outstanding case studies that stood out as particularly

innovative and enlightening for inclusion in this monograph; and

✹ Conducting in-depth site visits or telephone interviews with representatives

from each selected health plan.

Lastly, in order to highlight health plans’ efforts as employers supporting

employees’ breastfeeding, AAHP solicited additional information from each health

plan that responded to the employee questionnaire and summarized that information

in the section entitled, “Health Plans, as Employers, Supporting Breastfeeding

Mothers Who Return to Work” (see page 77).

During the summer of 2000, AAHP mailed queries about breastfeeding programs

to multiple contacts at all member health plans, including medical directors, health

plan staff concerned with women’s health, maternal and child health, tobacco

cessation, and corporate communications. In total, more than 800 health plan staff

were contacted through this mailing. The questionnaires were intentionally designed

to be brief, yet comprehensive enough to yield sufficient and useful information.

AAHP made the questionnaires available electronically and most submissions were

received via e-mailed attachment.
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AAHP received more than 30 submissions from health plans that serve a total of

41 million enrollees, have multiple product lines (commercial, Medicaid, and

Medicare), and are clearly committed to breastfeeding promotion. AAHP believes

that the submissions represent a fraction of the breastfeeding promotion programs

within health plans. There are a variety of reasons that health plans may have not

responded to the query: the plan might not have a formal breastfeeding promotion

program; the program might be new and/or not have outcome data; time constraints

may have precluded some plans with programs from responding to the survey; or

the health plan’s current quality improvement strategies focus on other areas of

health care services.

Each submission was screened by AAHP staff for key elements such as program

title, program components, goals, evaluation, and results to date. Any programs

which were minimal and informal—such as merely handing out educational

brochures at one prenatal visit—were not considered. The remaining submissions

were blinded, duplicated, and sent to all members of the Review Committee. In

cases where there would be conflict of interest (i.e., a committee member representing

a health plan that had submitted a questionnaire), staff did not send that submission

to the committee member in question. A rating chart was developed and sent to

each Review Committee member to help in the evaluation and ranking of the

programs.

The rating chart was developed following the 12 dimensions established in 1997

by the Women’s Health Subcommittee. These included:

1. Worthy, clear, and explicit goals and objectives

2. Ability to involve staff

For example, can administrative staff who enter data make suggestions

regarding data collection tools?

3. Willingness of providers

For instance, are providers interested in promoting the program to their

patients and are they committed to enhancing it?

4. Commitment of the health plan to the program

5. Innovative qualities of the program

In what ways does this program stand out from others? What makes it

unique?

6. Evaluation of the program, including quality, relevance, and validity of the

measures used

7. Outcomes achieved

8. Percentage of target population that participates in the program

9. Patient satisfaction

10. Program cost and effectiveness

11. Sustainability of the program

12. Replicability
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Using these criteria, the Review Committee selected the most outstanding

programs for inclusion in this monograph. In order to learn more about the health

plans’ innovative practices, staff then conducted in-depth interviews, either on-site

or by telephone, with each health plan. During these interviews, health plan

representatives answered detailed questions specific to their program.

A Lesson in Health Plan Variety

The programs included in the entire monograph series are making a difference

and advancing women’s health care. While the Breastfeeding Monograph Review

Committee selected programs based on their merits, the diversity of the plans

presented mirrors the diversity of the health plan industry as a whole. As a result,

the monograph offers “something for everyone.” Throughout the report, readers

will find examples of practices in IPA, staff, group and network-model HMOs and

PPOs (both not for-profit and for-profit organizations) that:

✹ Represent large, national chains and small, regional companies;

✹ Care for public (Medicaid) and private (commercial) populations;

✹ Serve urban and rural populations;

✹ Serve a variety of racially and ethnically diverse populations (AfricanAmerican, Hispanic, and Asian Pacific Islander);

✹ Serve teen mothers;

✹ Constantly refine and improve their program;

✹ Utilize strategies to increase program participation; and

✹ Partner with community-based organizations and statewide agencies to

maximize resources and increase effectiveness.

Note: While each program described in the monograph has unique qualities, only some have proven

effectiveness. In addition, some programs could only provide limited information in some areas. For

example, some featured health plans could not provide data on the exact cost of a given program. In

these instances, health plan contacts estimated costs as best as possible, but because of the complex

way in which individual departments assume direct and indirect costs, these figures may be

underestimated.
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Overview: Focus on Breastfeeding

Introduction

According to the HHS Blueprint for Action on Breastfeeding, a national

comprehensive breastfeeding policy released by the Surgeon General in October

2000, “extensive research on the biology of human milk and on the health outcomes

associated with breastfeeding has established that breastfeeding is more beneficial

than formula feeding (1).” Breastfeeding promotes infant and maternal health and

thereby lowers medical costs by decreasing the frequency of doctor visits,

hospitalizations, and medication utilization. As a result, the decision to breastfeed

is of significant importance to the newborn child, the mother, the health care system,

and the healthcare economy. Health plans can play key roles in encouraging women

and their families to start and continue breastfeeding.

Benefits to Baby

The HHS Blueprint for Action on Breastfeeding outlines several important health

benefits for breastfed babies, including resistance to infectious disease, enhancement

to the immune system, nutritional and growth benefits, reduced risk for chronic

diseases, and possibly cognitive benefits (1).

✹ Human milk contains an abundance of factors that are active against infection;

breastfeeding offers resistance to infectious diseases. Research demonstrates

that several infections are lower in incidence or severity in breastfed infants

than in formula-fed infants. These infections include diarrhea (2-6) respiratory

tract infections (2-3, 6-9), otitis media (4, 10-12), pneumonia (13-14), urinary

infection (15-16), necrotizing enterocolitis (17-18), and invasive bacterial

infection (19-22).

✹ Breastfeeding enhances a baby’s immune system. Research indicates that

breastfed infants, compared with formula-fed infants, produce enhanced

immune response to polio, tetanus, diptheria, and Haemophilus influenzae

immunizations, as well as to a common infant respiratory infection called

respiratory synctial virus infection (19, 23- 24). There is also evidence that

breastfeeding results in earlier development of the infant immune system (25).

✹ Human milk contains a balance of nutrients that more closely matches human

infant requirements for growth and development than does the milk of any

other species (26). For example, compared to cow’s milk, human milk is low

in total protein and low in casein, making it more readily digestible and less

stressful on the immature kidneys of infants. In addition, the lipids and

enzymes in human milk promote efficient digestion and utilization of nutrients

(26-27).

✹ Recent studies in infant feeding suggest that breastfeeding may reduce the risk

of type 1 and 2 diabetes (28-32), celiac disease (33-36), inflammatory bowel

disease (37-39), childhood cancer (40-42), and allergic disease/asthma (43-

48). Mixed results from some studies suggest that further research is needed to

establish some of these benefits (49-52).
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While any length of breastfeeding is better than no breastfeeding, research

indicates that exclusive and prolonged breastfeeding has a greater preventative effect

than short-term nursing or nursing along with supplemental formula feeding. A

recent study determined that infants categorized as exclusively breastfed, mostly

breastfed, and equally breastfed (with even amounts of breastfeeding and formula

feeding) for the first six months encountered lower rates of diarrhea, cough or

wheezing than those who were not breastfed (7). The HHS Blueprint for Action on

Breastfeeding, recommends that mothers breastfeed their babies exclusively for the

first four to six months, preferably a full six months. The Healthy People 2010

recommendation is to include breastfeeding, with solid foods added, until the baby’s

first birthday.

Benefits to Mother

Breastfeeding is also advantageous to maternal health. The HHS Blueprint for

Action on Breastfeeding (53) states, “breastfeeding has several positive hormonal,

physical, and psychosocial effects on the mother” and lists the following benefits:

✹ Breastfeeding increases levels of oxytocin, a hormone that stimulates uterine

contractions, helping to expel the placenta, to minimize postpartum maternal

blood loss, and to induce a more rapid return of the uterus to normal size (54-

55);

✹ Breastfeeding, particularly exclusive breastfeeding, postpones the resumption

of normal ovarian cycles and the return of fertility in most women (56)—

although breastfeeding should not be relied upon as a contraceptive;

✹ Mothers who breastfeed their infants may also experience psychological

benefits, such as increased self-confidence and facilitated bonding with their

infants (57-59);

✹ Studies have shown that breastfeeding for longer time periods (up to two

years) and among younger mothers (early 20s) may reduce the risk of

premenopausal and possibly postmenopausal breast cancer (60-65);

✹ The risk of ovarian cancer may be lower among women who have breastfed

their children (66-68).

Economic Benefits

Breastfeeding has economic benefits to individual families and health plans.

For families who choose breastfeeding as the method of infant feeding, costs of

infant feeding are substantially reduced. Even after accounting for the costs of breast

pump equipment and additional food required by the nursing mother, families can

save several hundred dollars over the course of the infant’s first year (69).

Because breastfed babies are in general healthier than non-breastfed babies,

breastfed babies typically require fewer sick care visits, prescriptions, and

hospitalizations, particularly if they are breastfed exclusively or almost exclusively

(70). Consequently, as noted in the HHS Blueprint for Action, total medical care

expenditures are about 20% lower for fully breastfed infants than for never-breastfed

infants (71).

Employers also reap benefits when their employees breastfeed. Because breastfed

infants are sick less frequently, maternal absenteeism from work is significantly

lower in companies with established lactation programs (72).
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Breastfeeding as a Public Health Challenge

The short- and long-term benefits of breastfeeding for babies and mothers are

well recognized, but the breastfeeding rates of American women remain low,

particularly among racial and ethnic minority groups. The breastfeeding goals of

Healthy People 2000—the precursor to the more recent Healthy People 2010—

were to increase to at least 75% the proportion of mothers who breastfeed their

babies in the early postpartum period and to at least 50% the proportion who continue

breastfeeding until their babies are five to six months old (73). Unfortunately, the

goals were not met and the overall rates for breastfeeding in the U.S. are low,

especially at six months postpartum. In 1998, the year for which the most recent

data are available, 64% of all mothers breastfed in the early postpartum period, and

only 29% of all mothers were breastfeeding six months after their child’s birth (74).

In fact, many mothers choose formula and/or quit breastfeeding within the first few

weeks after giving birth (75).

Minority populations, along with low-income families and less educated mothers,

breastfeed their babies at even lower rates. According to 1998 data cited in Healthy

People 2010, 45% of African-American mothers breastfed their infants in the early

postpartum period; 66% of Hispanic mothers and 68% of white mothers breastfed.

Only 19% of African-American mothers were still breastfeeding at six months,

compared to 28% of Hispanic mothers and 31% of white mothers (74). In addition,

only 54% of low-income Asian and Pacific Islander children and 59% of American

Indian and Alaska Native children were ever breastfed (76). These statistics highlight

the need for health plans and clinicians to address racial and ethnic disparities

surrounding breastfeeding by targeting minorities and/or economically

disadvantaged mothers.

Role of Health Plans

Health maintenance organizations (HMOs), preferred provider organizations

(PPOs), point-of-service (POS) plans, and all other health plan types, share a common

focus on disease prevention and health promotion along with a commitment to

providing comprehensive services. Health plans are in a unique position to influence

both health care consumers (women and their families) and health care providers

through targeted educational interventions promoting breastfeeding.

Women are more likely to breastfeed and be more persistent in their endeavor

when they are fully informed about the benefits. Physicians, and other healthcare

providers, should educate all prospective mothers about the health benefits of

breastfeeding (77). Education is critical because women decide whether or not to

breastfeed early—either before pregnancy or, in most cases, by the end of the second

trimester (78). Before the baby’s birth, health plans can provide a variety of

educational components that promote breastfeeding, including informative brochures

and videos, regular discussion during prenatal visits, and lactation classes.

According to the HHS Blueprint, “a woman’s ability to optimally breastfeed her

infant depends on the support she receives from those around her...The overriding

principle is to make breastfeeding as easy as possible for the mother rather than to

discourage her from breastfeeding, either intentionally or unintentionally” (79).

After birth, the health plan can offer specialized support—such as lactation

consultation (in hospitals, doctors’ offices and/or women’s homes), postpartum visits,

nurse advice lines, breast pump rental, and/or partial reimbursement for breast pump

purchases—that help women solve problems and continue breastfeeding.
24

Health plans can work with providers to make women aware that breastfeeding

may not come naturally, and to teach them the specific techniques and procedures

that will help them be successful. Within the first hour following birth, or one-half

hour is for best suckling reflex (58), so healthcare providers should be actively

involved in initiating breastfeeding and facilitating breastfeeding techniques during

that time. Lactation consultants should be easily accessible. Newly nursing mothers

benefit from meeting with lactation consultants who can evaluate the mother-andbaby team and provide ongoing advice and encouragement. Mothers in the early

postpartum period are especially sensitive as they adjust to common problems, such

as insecurities, lack of sleep, engorgement, poor latch, sore nipples, or more rare

occurrences such as inverted nipples or breast infections. Mothers need reassurance

and support from doctors, nurses, and other healthcare providers, as well as partners

and family members, in order to overcome what may be a temporary setback.

Returning to the Workplace

Returning to the workplace usually means separating from infants and can be

very difficult for mothers, especially those who breastfeed. Many breastfeeding

mothers choose to wean their babies rather than endure the added stress of working

and expressing and storing their breast milk. Healthcare providers can help delay

weaning by providing information in advance about ways to incorporate pumping

and/or nursing into the working day. Expressing and storing breast milk is a skill

that should be taught to all new mothers, in case of separation (80).

Preview of Monograph

This monograph highlights the outstanding programs of eight health plans that

promote breastfeeding among enrollees.

✹ Health Net, Inc. has developed a Strategic Action Plan for the Promotion of

Breastfeeding to address the decrease in breastfeeding prevalence among the

Medicaid populations the health plan serves. The strategy is comprised of

specific action plans to address breastfeeding through provider education,

member education, provider network management services, public health

coordination, and corporate commitment.

✹ HealthPartners provides comprehensive services, including prenatal education

and support, discharge planning, postpartum lactation support, and assistance

with rental or purchase of breast pump equipment, through its Breastfeeding

& Parent Support Center.

✹ Independent Health has a Prenatal Case Management Program that targets

members who are identified as high risk for pregnancy complications. Home

visits by nurses form the centerpiece of this program. Breastfeeding is

promoted in a variety of ways, including prenatal education, postpartum visits,

and breast pump rental.

✹ Kaiser Health Plan of Georgia promotes breastfeeding through a series of

educational components, including a specially-produced video, “Celebrate the

Miracle”, educational handouts, no-cost breastfeeding classes, continuing

education for providers, and postpartum lactation support.
25

✹ Kaiser Permanente Northwest has a Mother-Baby Program that incorporates

prenatal education, inpatient lactation support, and outpatient lactation

consultation services. In addition, through staff education efforts, Kaiser

Permanente Northwest ensures that the health plan’s strong commitment to

breastfeeding promotion is demonstrated in all member services. In January

2000, Kaiser Permanente Northwest’s hospital became one of only two dozen

hospitals in the United States to earn the World Health Organization’s official

designation as “Baby Friendly.”

✹ Kaiser Permanente of Southern California has a comprehensive program that

includes prenatal education, inpatient lactation support, postpartum outpatient

support, a breastfeeding information line, breast pump rental services, and

provider education. The health plan has several Medical Centers, each of

which serves a unique racial/ethnic membership composition. Educational

programs, classes, and services are developed to meet the specific needs of the

community.

✹ Keystone Health Plan East’s Baby BluePrints (or Baby Footsteps as the

program is called outside of Pennsylvania), is a comprehensive perinatal

program including prenatal risk assessment, information dissemination, case

management, and postpartum services for at-risk mothers and newborns.

Specific breastfeeding promotion activities include prenatal education about

breastfeeding, partial reimbursement for lactation classes and breast pump

purchase, postpartum lactation consultations (including in-home visits), nocost rental of breast pumps for medical necessity, and referrals to community

resources.

✹ UCare Minnesota has a Breastfeeding Promotion Program featuring strong

community partnerships with state and local public health agencies and

educational components targeted to all Minnesota residents, with particular

emphasis on pregnant Medicaid enrollees and their families. UCare has also

provided funding for a breastfeeding intervention targeted specifically to the

Hmong population in Minnesota.
26
27

Case Study I—Health Net, Inc.

(Oakland, CA)

Strategic Action Plan for the

Promotion of Breastfeeding

Program Development

and Implementation

Overview

In June 1999, Health Net developed

a Strategic Action Plan for the

Promotion of Breastfeeding to address

the decrease in breastfeeding

prevalence among the Medicaid

populations the health plan serves. The

strategy is comprised of specific action

plans to address breastfeeding through

provider education, member education,

provider network management

services, public health coordination,

and corporate commitment. By

integrating these efforts into existing prevention and public health programs, Health

Net has successfully established a comprehensive approach to breastfeeding

education, encouragement, and support for both providers and members.

Background

In 1996, Health Net developed a public health coordination department to be

responsible for communication, coordination, and collaboration with state and local

public health departments. This direct link to state and local public health departments

and to the community has enabled Health Net to be aware of and involved in the

public health issues important to the California Medicaid (Medi-Cal) population.

In 1996, the California Department of Health Services’ Breastfeeding Promotion

Committee, of which Health Net is a member, released a report indicating that

breastfeeding rates in California were declining. Health Net noted that in the counties

where Health Net served the Medi-Cal population, the breastfeeding rates were

among the lowest in the state. Furthermore, data from 1997 showed that while 78%

of women from California hospitals were breastfeeding at discharge, only 43%

were breastfeeding exclusively. In several counties that Health Net serviced, the

rate of exclusive breastfeeding decreased dramatically in the 10 years from 1987 to

1997.

Health Net, Inc., (formerly known as

Foundation Health Systems, Inc.) is one of

the nation’s largest publicly traded managed

health care companies. The company’s HMO,

insured PPO and government contracts

subsidiaries provide health benefits to

approximately 5.3 million individuals in 16

states through group, individual, Medicare

risk, Medicaid and TRICARE programs.

Health Net, Inc. subsidiaries also offer

managed health care products related to

behavioral health, dental, vision and

prescription drugs, and offer managed health

care coordination for multi-region employers

and administrative services for medical

groups and self-funded benefits programs.
28

The Breastfeeding Promotion Committee report, “Breastfeeding, Investing in

California’s Future,” identified several barriers to successful breastfeeding in

California, including women’s lack of knowledge and support for breastfeeding;

distribution of formula samples; separation of mothers and infants in the early

postpartum period; early discharge from hospitals and lack of follow-up; and

inadequate support by health care professionals. These findings prompted Health

Net to develop a Strategic Action Plan for the Promotion of Breastfeeding in June

1999 to identify opportunities to promote and support breastfeeding within

preexisting health plan systems. This method to integrate breastfeeding promotion

into various aspects of Health Net’s services was designed to complement activities

already underway in the State of California through existing organizational structure.

The strategic action plan was written with the intention of further promoting

partnerships and establishing new links with local public health departments and

community-based organizations. Health Net developed the following policy

statement as the basis for the health plan’s initiative:

“Recognizing the significant health and economic benefits to mothers, infants,

and society, Health Net endorses breastfeeding as the best infant feeding method

and urges contracting providers to enthusiastically promote and support

breastfeeding.”

Through Health Net’s Strategic Action Plan for the Promotion of Breastfeeding,

the health plan integrates provider education and network management services,

member education and benefits design, public health coordination, and corporate

commitment to implement a comprehensive approach to breastfeeding promotion

and support.

Goals

Health Net’s Strategic Action Plan for the Promotion of Breastfeeding strives to

increase member and provider awareness of the benefits of breastfeeding, specifically

through the first year of life and thereafter as desired by the member. To achieve

this goal, Health Net emphasizes the essential role of provider contracting in

influencing infant feeding decisions by members.

Target Population

Health Net’s breastfeeding initiative specifically targets pregnant Medi-Cal

enrollees and the providers with which the health plan contracts to provide services.

Essential Program Elements

Provider Services

✹ Provider Contracting. Health Net requires all Medi-Cal prenatal care providers

in its network to be DHS (Department of Health Services) certified

Comprehensive Perinatal Services Program (CPSP)-providers or to develop

formal agreements with certified CPSP providers. CPSP-certified providers

receive technical assistance, education, and support from their local public

health departments related to nutrition, psychosocial issues, and health

education. This contracting strategy ensures that all Health Net Medi-Cal

prenatal care providers are well educated about public health issues specific to

the Medicaid population, including breastfeeding.
29

✹ Provider Education. Health Net’s Provider Education Staff influence office

practice systems by providing network providers with research materials

about breastfeeding, discussing the role of physicians in promoting

breastfeeding, and encouraging pediatric care providers to participate in the

American Academy of Pediatrics’ “Breastfeeding Promotion in Pediatric

Office Practice” program. A provider education breastfeeding packet is

available that includes reproducible patient education materials, clinician

reference materials, information related to different cultural food habits and

diet during pregnancy and lactation, and education resources. In addition,

through a quarterly provider publication, “Physician News,” Health Net

provides information related to the health and economic benefits of

breastfeeding, strategies to overcome common barriers to breastfeeding,

inadequacies of artificial baby milk, and strategies for providers to promote

breastfeeding. The health plan also encourages participation in educational

opportunities offered by reputable Continuing Medical Education (CME)

courses.

✹ Breastfeeding Protocols. Health Net worked with local health departments’

maternal and child health (MCH) programs, Regional Perinatal Programs of

California, and other agencies in Health Net’s Medi-Cal counties to establish

county-specific CPSP protocols that include breastfeeding promotion and

support information and materials, and are distributed to all Health Net

obstetrical care providers. Providers use answers to the Prenatal Combined

Assessment/Reassessment Tool to determine what further actions are

necessary, if any, and work with the patient to prepare an individualized care

plan. Health Net’s protocols provide culture-specific recommendations and

suggestions for various ethnic groups. The protocols have been reviewed for

cultural competency by cultural/linguistic specialists as part of a State DHS

MCH grant, as well as by State Breastfeeding Promotion Committee

members.

Member Services

✹ Member Education. Health Net’s health education department provides new

member packets, health education classes, and health education materials

directly to enrollees or through providers. Health Net’s member relations staff

make personalized telephone calls to all new Medi-Cal enrollees to inform

them about and assist with utilization of available Health Net services.

Pregnant members are informed about the health plan’s promotion of

breastfeeding and encouraged to call a toll-free nutrition information line to

speak with a lactation consultant. The member relations staff speak several

languages, including English, Spanish, Vietnamese, Cantonese, and Hmong.

In addition, with their consent, pregnant members are sent a prenatal packet of

information specific to the county in which they live. Health Net also

produces and distributes a quarterly newsletter for Medi-Cal enrollees, entitled

“Being Well.” Articles on health topics draw attention to important issues such

as breastfeeding. The publication is produced in English and Spanish, and

translation into other languages is available by calling the member relations

department.
30

✹ Nutrition Information Line. A nutrition information line available for all

Medi-Cal members has been in existence for the past two years. This free

personalized phone service, offered in English and Spanish, is advertised

statewide and provides direct access to a registered dietitian/lactation

consultant who is available to answer all nutrition inquiries, including

questions about breastfeeding. While most inquiries are not crisis calls, about

10-15% of calls are concerned with breastfeeding issues, such as maternal

eating habits, breast pumping, or returning to work. Following each phone

call, the member is asked if she would like to receive additional literature.

✹ Breast Pump Benefit. Health Net provides breast pumps as a covered benefit

when medically necessary for mother or child, and for Medi-Cal enrolled

mothers who are exclusively breastfeeding and returning to work or school.

Lactation durable medical equipment does not require prior authorization for

the first two months of use.

✹ Lactation Consultation. Under Health Net’s benefits structure, referral may be

made to lactation consultant services when medically necessary. The first two

visits do not require prior authorization.

Community Efforts

✹ Public Health Coordination. A member of the public health coordination

department represents Health Net on the California Breastfeeding Promotion

Advisory Committee. In addition, staff work with local WIC programs on

World Breastfeeding Week activities and seek opportunities to collaborate

with the Regional Perinatal Programs of California on educating hospital staff

about best practices for breastfeeding promotion. In this way, Health Net

strives to build on existing breastfeeding promotion activities and works to

incorporate successful strategies into member and provider services.

Evaluation and Outcomes

Evaluation

Health Net acknowledges that breastfeeding outcome data are difficult

to track over an extended period of time because of the transient nature

of the Medicaid population. The health plan chooses rather to assess the

community health overall using information from local breastfeeding

coalitions and hospital discharge data. It is expected that new county

and hospital-specific data will be available this year.

Cost

Health Net’s approach to promoting breastfeeding is not financially intensive

because much of the initiative is based on the incorporation of breastfeeding

promotion into existing member and provider outreach efforts. While set-up and

administration of the nutrition information line represents an expense to the health

plan, Provider and member relations departments were already in existence to

communicate with providers and members on a variety of health issues. The minimal

costs directly related to breastfeeding promotion include staff time and expenses

associated with mailings to both providers and members.

Health Net’s Strategic Action Plan

for the Promotion of Breastfeeding

states, “Promoting breastfeeding

requires a change in approach, not a

capital investment.”
31

Lessons Learned

In the administration of a Medicaid-focused breastfeeding initiative, health plans

struggle with competing priorities, limited resources, and providers’ resistance. The

presence of the Comprehensive Perinatal Services Program as part of Medi-Cal

contributes to Health Net’s ability to emphasize breastfeeding through provider

contracting. This same association would not be present in a commercial population.

In addition, many providers are uninformed about the health benefits of

breastfeeding. Even though a number of the State Breastfeeding Promotion

Committee members are working with medical schools in California, breastfeeding

and lactation support are not a focus of core residency training. To ensure that

participating providers are aware of the policy and to promote the strategy, Health

Net’s Medi-Cal Medical Directors for both Northern and Southern California present

information about the company-wide initiative during Medi-Cal physician meetings

and Joint Operations meetings. Health Net has received multiple inquiries from

other health plans about the industry-leading strategy and finds that providers are

receptive to the approach which provides them with education and necessary

resources to encourage breastfeeding for their patients.

Directions for the Future

In the future, Health Net will strive to publish at least one breastfeeding article

annually in both the physician and member newsletters. The health plan also hopes

to design and implement online continuing medical education courses and credits

specifically addressing breastfeeding topics to encourage increased education and

awareness about the health benefits of this feeding method. The public health

coordination department will continue to work with government programs and

community groups to promote and encourage breastfeeding throughout the counties

Health Net serves. Additionally, Health Net corporately supports good nutrition,

including breastfeeding, through partnerships such as its sponsorship of the California

Association of WIC Directors’ meeting in Spring 2001 in San Diego.

Health Plan Contact Information

Judith Sell-Gutowski, RN, MS

Senior Public Health Programs Administrator

Health Net

155 Grand Avenue

Oakland, CA 94612

Tel: 510.287.4532

Fax: 510.287.4673

E-mail: Judith.Sell-Gutowski@healthnet.com
32
33

Case Study II—HealthPartners

(Minneapolis, MN)

Breastfeeding & Parent Support Center

Program Development

and Implementation

Overview

HealthPartners has established a

comprehensive, centralized approach to

encouraging breastfeeding in the

community as a whole. Through the

HealthPartners Breastfeeding & Parent

Support Center, experienced and

knowledgeable staff provide a full

range of breastfeeding services to

pregnant women and their families,

including prenatal educational services,

discharge planning, postpartum

lactation support, and breastfeeding equipment. The health plan has gone one step

further by making services available to women represented by a majority of other

local health plans and by educating other health care colleagues and institutions

about the importance of breastfeeding as the best feeding option.

Background

In the 1980s, during a period of intense health plan growth, HealthPartners sought

support within the health plan for innovative programs in health care delivery. A

focus on breastfeeding was championed at HealthPartners’ Como Clinic by a

pediatric nurse practitioner (PNP) who had become a certified lactation consultant.

She approached the head of HealthPartners’ pediatrics department to discuss the

development and implementation of a program to promote breastfeeding within the

membership. Work began in January 1992 when lactation visits were incorporated

into the PNP’s pediatric schedules, and formal implementation of the HealthPartners

Breastfeeding & Parent Support Center began in 1993.

Since that time, staffing has increased to include a director, several International

Board Certified Lactation Consultants (IBCLCs) (both certified pediatric nurse

practitioners and registered nurses), and support staff. Remodeling has allowed for

four rooms in the Como Clinic to be dedicated to outpatient lactation support. In

addition, HealthPartners has developed a consumer breastfeeding book, designed

and offered classes to promote and encourage breastfeeding, developed lactation

care and After Hours Care Nurse (AHCN) guidelines, designed a breastfeeding log

and assessment sheet, collaborated on hospital discharge triage guidelines, and

improved marketing efforts to include advertisements in the yellow pages,

HealthPartner’s newsletters, and a special website.

HealthPartners is a family of consumergoverned nonprofit Minnesota health care

organizations. HealthPartners and its

related organizations provide health care

services, insurance and HMO coverage to

nearly 650,000 members. More than 9,500

employees staff the various HealthPartners

organizations. The HealthPartners family

includes the HealthPartners Medical

Group and Clinics, RiverWay Clinics,

HealthPartners Central Minnesota Clinics,

HealthPartners Dental Group and Clinics,

Regions Hospital, Regions Hospital

Foundation, HealthPartners Research

Foundation, HealthPartners Institute for

Medical Education, and Group Health, Inc.
34

 Target Population

While the program is targeted to all pregnant woman who are enrolled in

HealthPartners health plans, all services are also available for the women represented

by a majority of other payors in the area with a referral from the obstetric or pediatric

provider or as fee-for-service. The clinic staff also serves an advocacy role in the

community by being a resource for Twin Cities’ health professionals. Since the

development of a formalized program in the early 1990s, HealthPartners’ staff have

encouraged the hiring of lactation consultants at various Twin Cities’ hospitals and

presented information at other area venues, including didactic sessions and clinical

fieldwork for all University of Minnesota pediatric residents and some PNP students,

nurse-midwife students, and nurses.

While the breastfeeding initiative does not specifically target minority

populations, all HealthPartners staff attend diversity training and years of experience

have allowed them to learn about sensitive cultural issues by talking with the mothers.

Teen mothers are targeted as high-risk in hospital discharge triage guidelines and

staff work with them specifically to deal with returning to school or work.

Goals

The goals of the HealthPartners Breastfeeding & Parent Support Center are to

provide education and assistance with the promotion, establishment, and maintenance

of breastfeeding, including surpassing the Healthy People 2010 goals.

Essential Program Elements

✹ Prenatal Education and Support. Breastfeeding is a major topic discussed in

prenatal classes and seminars offered by HealthPartners, including the

“Breastfeeding Your Baby” class. Obstetric providers discuss breastfeeding as

a feeding option during prenatal visits. In addition, HealthPartners includes

information about the services available through the Como Clinic’s Lactation

Center in prenatal packets distributed to all pregnant members. In an effort to

identify potential problems before birth, the health plan also performs breast

assessments on pregnant members.

✹ Discharge Planning. At about 32 weeks of pregnancy, a care coordinator nurse

calls each pregnant woman to discuss feeding options and resources available

through the program. This call also provides an opportunity for the health plan

to seek information about whether the mother is planning to breastfeed, her

family support system, and many other postpartum planning issues.

HealthPartners has also developed discharge guidelines to assess the type of

postpartum support a mother needs. A newly delivered mother may receive a

home visit and/or be referred for a visit to the outpatient lactation clinic.

✹ Postpartum Lactation Support. All newly delivered mothers who are

breastfeeding receive a lactation assessment over the phone three to five days

postpartum. In addition, HealthPartners has designed a breastfeeding log and

self-assessment sheet that are given to all breastfeeding mothers prior to

discharge. Mothers are asked to bring the filled-in logs to the one- or twoweek pediatrician visit. These forms allow pediatric providers to assess

lactation in the first one to two weeks postpartum and identify any “red flags”

that may require personal attention by a lactation consultant.
35

If necessary, a one-hour outpatient lactation consult is scheduled at the Como

Clinic and includes education about effective breastfeeding techniques and a

newborn physical assessment if the baby is less than one week old. If followup care is necessary, the Center’s staff coordinate with primary care providers,

home care, or other services. Strong communication between the Center and

other facilities and providers is a key component to the success of the

program. Office and phone consultation are available at the Breastfeeding &

Parent Support Center Monday through Friday, 8:30 a.m. to 5:00 p.m.

Newly delivered mothers also receive HealthPartners’ breastfeeding book, in

its fifth edition, which includes comprehensive information about such topics

as preparation during pregnancy, the mother’s nutrition, breastfeeding

positions, what to expect, returning to work, collecting breast milk, and

weaning. This popular guide is offered in Spanish and is often inquired about

by other Minnesota agencies.

Other postpartum services available through the program are a no-cost “Back

to Work & Breastfeeding” class and an infant massage class with a nominal

fee. These classes are offered twice a month and attendance is kept small to

allow for individualized attention.

✹ Breastfeeding Equipment. HealthPartners offers both rental and purchasable

breastfeeding equipment, including: electric, manual, and pedal breast pumps;

slings; nursing pillows; washable bra pads; massage oils; and lanolin cream.

The health plan charges a markup significantly less than that found in the

community and the revenue generated through sales and rentals helps to

provide viability for the overall program. Equipment demonstrations are

provided daily by lactation consultants and the lactation support staff.

For low-income residents who are eligible for either Medicaid or MinnesotaCare,

(a program for Minnesotans who do not qualify for Medicaid but are low-income

and without insurance), HealthPartners provides pro-bono supplies and care.

Evaluation and Outcomes

Evaluation

In 1996, HealthPartners completed a survey of members from its medical group

clinics to assess patient satisfaction and breastfeeding frequency. Results indicated

high patient satisfaction with the Lactation Center services. The breastfeeding

initiation rate was 80-85%; this frequency was nearly the same at five weeks

postpartum. Breastfeeding frequency was approximately 65% at three months

postpartum and approximately 40% at six months postpartum. (The national average

is 29% at six months). Follow-up surveys continue to document extremely high

patient satisfaction and high quality service.

Outcomes

Currently, all HealthPartners’ medical group clinics combined have 3,200

deliveries per year and the Breastfeeding & Parent Support Center performs 2,000-

2,500 consults per year at the Lactation Center, making it the largest non-hospitalbased lactation facility in the United States. In addition, the staff responds to over

7,000 phone calls each year and about 20% of the patients called are subsequently

seen in the clinic.
36

Cost

Although cost savings associated with medical benefits are a direct result of the

initiative, the impetus for the HealthPartners’ breastfeeding support program has

always been patient satisfaction and a desire to promote the healthiest feeding option

for both mother and child. The HealthPartners Breastfeeding & Parent Support

Center generates a net revenue of $40,000 per year from equipment rentals and

sales, making the program a profitable venture. The gross charges associated with

lactation consults is approximately $250,000 per year and the staffing budget is

about $150,000 per year. Fixed costs are negligible.

Replicability

HealthPartners credits the success of its program to the depth of experience

represented by the specialized staff and the consistent presence of a provider

champion to promote the effort. The health plan also recommends that during initial

stages of development, a centralized location for breastfeeding support is beneficial.

HealthPartners’ Breastfeeding & Parent Support Center is located within the

HealthPartners’ Como Clinic. The clinic is an easy 20-minute drive from most areas

of the Twin Cities. Equipment and services are centralized, which facilitates the

sharing of information among lactation specialists.

Lessons Learned

HealthPartners staff advise that corporate support for a breastfeeding program,

including information services, marketing, and finance, is essential. In addition,

community collaboration allows for increased efficiency. Science-based care delivery

is also crucial for high quality of care, reproducible results, and credibility with

health professionals. Interdepartmental interface and communication between

pediatrics, obstetrics, and family practice is essential. Further, educational efforts

must be constant and repetitive.

Directions for the Future

HealthPartners hopes to make the breastfeeding website more interactive and

user-friendly in the future. Plans include offering e-mail capabilities to allow

members to ask questions electronically, providing educational links, and allowing

electronic class registration. Also, HealthPartners hopes to set-up an enhanced

electronic tracking mechanism within the next year to observe breastfeeding rates,

demographic and perinatal data, referral sources, diagnoses addressed, and utilization

and productivity data. Such a system will contribute to piloting the program at

other satellite offices by allowing all sites access to care guidelines and parent

handouts, enhanced equipment inventory tracking, and billing oversight and

collections assistance. This in turn will allow Lactation Center staff to spend more

time with patients.

The health plan also hopes to increase call coverage to include the weekends

and will develop new programs to target efforts to groups with low breastfeeding

prevalence and/or longevity. They will continue to translate breastfeeding support

materials into key languages and HealthPartners is interested in exploring clinical

research opportunities and collaborations.
37

Health Plan Contact Information

Teresa Kovarik, M.D.

Director, HealthPartners Breastfeeding & Parent Support Center

HealthPartners Medical Group

Department of Pediatric and Adolescent Medicine

2500 Como Avenue

St. Paul MN 55108

Tel: (651) 641-6217

Fax: (651) 641-6255

E-mail: Teresa.F.Kovarik@healthpartners.com

website: www.healthpartners.com
38
39

Case Study III—Independent Health

(Buffalo, NY)

Prenatal Case Management

Program Development

and Implementation

Overview and Goals

Independent Health’s Prenatal Case

Management Program is designed to assist members who are identified as high risk

for pregnancy complications. The program facilitates access to and encourages

appropriate use of prenatal healthcare services, which are important factors in

improving the outcome of a pregnancy.

Two registered nurses, with vast OB experience, work directly with prenatal

nurses from home care agencies to coordinate home visits and health education for

high-risk pregnant members and those enrolled in MediSource (i.e., Medicaid).

The overall goals of the program are to identify risk factors and provide appropriate

interventions to decrease the incidence of premature and low birth weight babies.

Specific goals are to:

✹ Identify early and manage all high-risk pregnancies;

✹ Increase gestational age to greater than or equal to 37 weeks;

✹ Increase birth weight to greater than or equal to 2,500 grams;

✹ Minimize antenatal hospitalizations; and

✹ Provide participants with education and linkages to community services.

Breastfeeding is one of the many topics discussed during home visits. Pamphlets

and other educational materials are distributed to reinforce material covered at these

teaching sessions. Every woman enrolled in the Prenatal Case Management Program

receives one postpartum home visit. At this visit, breastfeeding mothers receive

help with any nursing problems they might be experiencing.

The majority of Independent Health’s pregnant members are considered to be

low risk and therefore do not participate in the Prenatal Case Management Program.

However, Independent Health recognizes that these women also need breastfeeding

education. Combining efforts with various community-based organizations and

vendors, the health plan offers members discounts on breastfeeding and parenting

classes, breast pump rental, and lactation consultation.

Background

The impetus for Independent Health’s development of a Prenatal Case

Management Program in August 1996 was two-fold. One, health plan outcomes

data revealed an increase in the incidence of low birth weight babies. Second, in

order to expand into a Medicaid product line, the health plan had to comply with

New York Department of Health regulations that require implementation of a prenatal

case management program.

Independent Health is an

independent practice association

(IPA) model HMO serving 395,000

members in eight counties in

Western New York State.
40

Independent Health’s program focuses on identifying risk factors and helping

women comply with recommended prenatal care. Emphasis is placed on education

and prevention. A prenatal nurse from a participating home care agency visits each

woman enrolled in the program and completes a nutritional, environmental,

psychosocial, and physical assessment. Additional home visits are authorized as

needed for each member and referrals to necessary community services are provided.

The Prenatal Case Manager works closely with the physician and provider team in

mutually supporting the needs of each high-risk pregnant member.

Target Population

The target population for the Prenatal Case Management Program includes both

commercial health plan members who are identified as high risk for pregnancy

complications and all pregnant MediSource members. In 1999, 750 women

participated in the program.

Essential Program Elements

The heart of Independent Health’s Prenatal Case Management Program is the

identification of high-risk members and subsequent home visits by experienced

prenatal nurses.

Identification of High-Risk Pregnant Enrollees

Women at high risk are identified three ways: physician referral, claims data,

and hospital admissions data. Once the potential candidates have been identified,

case management staff score their risk factors and identify those who will receive

an in-home risk assessment from a home health nurse. Ideally, the first visit takes

place within a week to 10 days of a physician referral and within the first 12 weeks

of pregnancy if the woman is identified through claims or hospital admissions data.

Of course, many women delay seeking prenatal care and therefore may not be

identified and recruited until their fifth month of pregnancy or later.

Home Visits

At the first home visit, the nurse-who is a specialist in maternal/child healthdoes a basic health assessment (weight, blood pressure, urine check), addresses any

special health concerns (diabetes, hyperemesis, or bleeding), assesses the housing/

environmental situation (heat, electricity, general safety), and provides education,

including information about breastfeeding. In addition, the nurse will provide

referrals to appropriate community support (for example, in the case of domestic

violence), make sure that an application for the Special Supplemental Nutrition

Program for Women, Infants, and Children (WIC) is completed, and troubleshoot

any transportation problems the woman might face.

The completed health assessment is then faxed to the Prenatal Case Management

Program. A case manager summarizes it, attaches the nurse’s notes, and forwards

the entire report to the woman’s doctor. However, if the nurse identifies a serious or

potentially serious medical problem, she will immediately call the doctor. The two

obstetric (OB) nurses who staff Independent Health’s Prenatal Case Management

Program will also be in contact with the physician’s office to discuss a plan of care

as necessary.
41

In general, most participants receive a second visit at 32 weeks and a third visit

two to four weeks after the baby is born. Based on the nurse’s assessment and/or the

clinical course of the pregnancy, women may receive more visits as necessary.

Conversely, if the physician’s initial assessment suggests frequent visits, but the

nurse determines that the situation is improving, the number of visits may be

decreased. The idea is to meet the unique needs of each woman.

In that vein, there are no co-pays for these home visits, for either commercial or

MediSource members. The health plan is aware that commercial members at highrisk might not be working because they must be at home on bedrest. Therefore the

health plan has removed any potential economic barriers to those women receiving

the in-home care they need.

Independent Health has a variety of activities focused specifically on

breastfeeding:

✹ Once a woman is identified for the Prenatal Case Management Program, she

receives a welcoming cover letter and a booklet that covers a lot of prenatal

information, including breastfeeding.

✹ During the home health nurse visit, that booklet is referenced and the nurse

encourages breastfeeding.

✹ Obstetricians also promote breastfeeding. The Prenatal Case Management

Program communicates directly with obstetricians through educational articles

stressing the importance of breastfeeding and regular communiqués about

program components related to breastfeeding, such as breast pump rental

discounts.

✹ A newsletter-one for commercial members and one for MediSource membersis mailed routinely to pregnant women. Articles about breastfeeding are

included in that newsletter.

✹ After the baby is born, the nursing mother can receive help from a variety of

sources. The home health nurses can go back into the home to provide support

and guidance. Many of Independent Health’s pediatricians have lactation

consultants on staff and some hospitals have them as well. The health plan has

contracted with a vendor, Care Connection, that deals specifically with

breastfeeding. Care Connection provides pump rental, conducts classes, and

also provides lactation consultation. Independent Health also offers telephone

support through its 24-hour nurse triage line called TeleSource, as well as

through a service that provides audiotaped recordings on demand, including

one that addresses breastfeeding problems.

✹ Mothers and babies who meet certain medical criteria (preterm infant,

multiple gestation, Down’s Syndrome, cleft palate/lip, mother on medication)

that can preclude nursing can rent breast pumps through the health plan.

Depending on the members’ plan, the copay is either 50% or 20%. There is no

copayment for MediSource members.

Services Offered to Low-Risk Pregnant Members

In order to reach those low-risk women who represent the majority of Independent

Health’s pregnant enrollees, the health plan offers breastfeeding classes at a

discounted rate through the plan’s Feeling Fit Department. In addition, Independent

Health asks hospitals to identify live births and then sends out a cover letter along

with an educational packet on postpartum care that specifically encourages

breastfeeding and provides the TeleSource hotline number.
42

Evaluation and Outcomes

Since the inception of the program in 1996, a total of 2,701 members have been

recruited to participate and 2,116 of these members enrolled (a participation rate of

78%). Of the 2,116 who enrolled, 1,270 were MediSource members and 846 were

commercial HMO members. Commercial participants had a mean age of 28 years

old and 22% were minority. MediSource participants had a mean age of 24.7 years

old and 38% were minority.

The mean gestational age for MediSource members at enrollment has increased

since the launch of the program. In addition, the incidence of low birth weight

babies dropped significantly between 1997 and 1998 and dropped non-significantly

between 1998 and 1999. At this writing, data were not yet available for 2000.

MediSource members who participated in case management were 40% less likely

to deliver a low birth weight infant and 42% less likely to deliver pre-term.

For commercial members, the mean gestational age at enrollment into case

management showed a statistically significant decrease over time. The incidence of

low birth weight deliveries dropped significantly between 1997 and 1998, however

increased significantly between 1998 and 1999. Data were not yet available for

2000. Health plan staff speculate that the increase in low birth weight babies among

this population might be due to higher-order multiple births related to fertility

treatments. Members who participated in case management were 45% less likely to

deliver a low birth weight infant. There were no differences in the likelihood of

delivering pre-term.

While Independent Health has excellent information about the efficacy of the

program for both commercial and MediSource populations, it has not collected

information specific to the breastfeeding promotion components of the program.

Therefore, as of yet there are no outcomes data on the percentage of women who

breastfeed, the success of their breastfeeding experience, or the length of time they

continued breastfeeding.

In addition to outcomes data, Independent Health conducts a consumer

satisfaction survey each year for case management participants. Overall, satisfaction

is very high. For the seven specific satisfaction items on the survey, mean responses

on the 4-point scale were between 3.74 and 3.98, indicating that the majority of

respondents were very satisfied with the program. Overall ratings of the benefit of

the program indicated that 75% rated the program as very beneficial and 99% of

respondents felt the program was at least a little beneficial.

Cost

The health plan reports that on average, the two prenatal and one postpartum

nurse home visits cost $210 and an additional $10 is spent on educational materials

and postage for each member. Although the estimated program costs are $220 per

member, this figure does not include the cost of prescriptions, additional visits that

might be required, breast pump rental, or discounts offered on classes. Nor does it

include the other direct and indirect costs required to staff and run the program.
43

Replicability

Independent Health is proud that their program brings health professionals directly

into members’ homes. The health plan sees those in-home visits as essential for

replication of their Prenatal Case Management Program. Staff also note that waiving

a co-pay for these visits is critical and that such a decision obviously requires

significant management buy-in.

Program staff provide the following advice to other health plans seeking to follow

in their footsteps: “Have previous years’ birth outcomes data, set up a strong program

description, and know what you want to accomplish. Expect resistance, but keep

moving forward.”

Lessons Learned

Past consumer satisfaction surveys revealed some member dissatisfaction with

the written materials handed out by the nurses during the home visits. As a result,

Independent Health has created a new comprehensive educational package on the

topics of prenatal care, after delivery care, and newborn care. These educational

packets will be available for all members in the case management program in early

2001.

Prenatal Case Management staff state that when the program began, some

physicians were resistant to the program. Staff addressed this barrier by visiting

each doctor’s office, explaining the program, and giving examples about the costs

of caring for premature babies and how they can be diminished by spending a few

dollars upfront on this program. The job of convincing physicians to utilize the

program has become easier now that there is evidence of program efficacy.

Directions for the Future

Starting in 2001, the Prenatal Case Management Program will introduce an

“educational visit” to participants, so that even if a physician does not sign off on a

skilled nursing visit, the program can still get a nurse into the home to do a

psychosocial assessment and to figure out what other resources the woman might

need.

In addition, program staff are planning for the enhancement of a pediatric case

management program to follow babies born to high-risk mothers, and utilization of

a new software program that could be used to track breastfeeding information.

Health Plan Contact Information

Janet M.Stoeckl RNC, CCM

Case Management, Manager

Independent Health

511 Farber Lakes Drive

Buffalo, NY 14221

Tel: (716) 635-3915

Fax: (716) 631-1038

E-mail: jstoeckl@independenthealth.com
44
45

Case Study IV—Kaiser Health Plan of Georgia

(Atlanta, GA)

The Maternal/Child Health Lactation Program

Program Development

and Implementation

Overview and Goals

Kaiser Health Plan of Georgia’s

Maternal/Child Health Lactation

Program is a service provided by nurse

educators and lactation consultants in

coordination with the OB/GYN

practitioners, who include physicians,

nurse-midwives, nurse practitioners, and

physician assistants. The primary focus

of the program is education. Kaiser

Health Plan of Georgia has created several unique educational pieces—including a

video called “Celebrate the Miracle”—that form the core of a comprehensive prenatal

education program.

The Goals of the Lactation Portion of the Program are to:

✹ Provide enrolled pregnant women with the information to make decisions

about breastfeeding their newborns;

✹ Provide education to women planning to breastfeed;

✹ Provide support services to breastfeeding women; and

✹ Provide continued education to practitioners on lactation topics.

Kaiser Health Plan of Georgia’s overarching goal is to reach pregnant women

early and often with pro-breastfeeding messages from a variety of sources. As a

result, the health plan has created a number of prenatal educational opportunities

and expanded access to postpartum support by engaging a variety of providers,

including lactation consultants and nurse-midwives, in counseling efforts.

Background

Nurse-midwives have been essential to the development of the health plan’s

breastfeeding promotion activities. In the early 1990s, when nurse-midwives were

becoming part of Kaiser Health Plan of Georgia, they saw the need to make hospital

practices more conducive to breastfeeding. As champions of the program, they

worked hard to establish programs and practices that would encourage enrollees to

breastfeed. While they did not conduct a formal needs assessment, they drew upon

their knowledge of the literature that clearly demonstrates the benefits of

breastfeeding to mother and baby. Within the last several years, the health plan has

more purposefully developed and expanded the program through the efforts of the

Founded in 1945, Kaiser Permanente is

a nonprofit, group-practice health

maintenance organization (HMO) with

headquarters in Oakland, California.

Kaiser Permanente serves the health care

needs of members in 11 states and the

District of Columbia. It encompasses

Kaiser Foundation Health Plan, Inc.,

Kaiser Foundation Hospitals, and the

Permanente Medical Groups. Kaiser

Health Plan of Georgia is a group/staff

model HMO serving 270,000 members

in Atlanta, GA.
46

assistant manager for OB/GYN—who is herself a certified nurse-midwife—and

two lactation consultants. OB/GYN and pediatric practitioners were consulted in

the development of the program.

The program now includes special prenatal education for members, postpartum

support services, and continuing education for providers. While Kaiser Health Plan

of Georgia has not conducted an evaluation of the program, and therefore does not

have outcomes data, staff of the Maternal/Child Health Lactation Program believe

that they are making a difference in the lives of mothers and babies by consistently

sending clear messages and providing the skills and encouragement that support

breastfeeding.

Target Population

The target population for the Maternal/Child Health Lactation Program is all

pregnant women enrolled in Kaiser Health Plan of Georgia. Each year, the health

plan provides between 4,000-5,000 new OB visits, which result in approximately

3,000 births. (The difference between the two numbers reflects miscarriages, other

fetal deaths, and women leaving the plan prior to delivery.)

Essential Program Elements

Prenatal Education

An award-winning video called “Celebrate the Miracle” was produced by the

health plan specifically for its members. This video, which is shown to all women

during their first obstetric visit, begins the process of prenatal education. “Celebrate

the Miracle” covers basic information about prenatal care, nutrition, exercise, and

preparation for parenting. The video introduces the health plan’s concept of prenatal

care, encourages women to attend classes—including breastfeeding classes—and

delivers a strong message about the positive health aspects of breastfeeding.

The Healthy Mother/Healthy Baby Notebook is a manual that provides additional

prenatal education materials and includes an extensive section on breastfeeding.

“Expectations” is a series of 16 educational handouts designed as interactive tools.

At each prenatal visit, the woman and her practitioner review the contents of a

specific handout. Breastfeeding is one of the topics discussed.

Breastfeeding classes are offered in the evenings at no cost to members. Classes

help both to assist women with the decision to breastfeed and to teach the basics of

breastfeeding. Additional breastfeeding support is provided through ongoing

counseling and discussion during prenatal visits with either nurse-midwives or OB/

GYNs. Prenatal appointments with lactation consultants are also available for women

with special needs, such as twin gestations.

Postpartum Breastfeeding Support Services

A variety of lactation support services are offered. Women can bring their babies

in for a one-on-one visit with a certified lactation consultant that lasts anywhere

from 50 minutes to an hour-and-a-half, depending on the mother’s needs and the

baby’s cooperation. These visits are coordinated for the mother’s convenience so

that she can meet with a lactation consultant in an office near her home, without

necessarily having to travel to her own doctor’s office.
47

Kaiser Health Plan of Georgia is also planning to begin offering office visits

with nurse-midwives. Starting this year, the plan is to schedule breastfeeding

consultations with the nurse-midwives, which means that breastfeeding women

can choose to meet with the same provider who counseled them prenatally and

helped with the start of breastfeeding. The health plan believes that expanding access

to professionals who can provide breastfeeding support is essential to helping women

continue with breastfeeding.

For women who are in need of support after hospital discharge, including all

teen mothers, women who have had Cesarean sections, and other women identified

by the physicians or nurse-midwives as meeting certain medical criteria, the health

plan offers home visits from perinatal community nurses. The home health nurses

have specialized training in lactation support. Some of the nurses are employed

directly by the health plan while others work for an agency with which Kaiser

Health Plan of Georgia contracts. In addition, women whose babies are in the

Neonatal Intensive Care Unit (NICU) automatically receive a follow-up phone call

from a lactation consultant within one week. The lactation consultants continue to

monitor these mothers and babies through regular phone calls, as necessary.

For those mothers who are unable to come in for a lactation consultation or who

have questions, the health plan offers telephone consultations with certified lactation

consultants. Breastfeeding mothers can talk on the phone with a lactation consultant

Mondays through Fridays during office hours and can leave messages 24 hours a

day.

The lactation consultants also call all breastfeeding women at one and three

weeks after delivery.

In addition, Kaiser Health Plan of Georgia’s pediatric department has begun a

trial of group medical appointments for new mothers and their babies at the time of

the two-week appointment. The group appointment provides new mothers the

opportunity to meet, in a group, with a pediatrician to discuss newborn care,

breastfeeding, and other relevant issues.

Continuing Education for Providers

In order to increase providers’ knowledge about breastfeeding and to augment

their abilities to support breastfeeding women, the health plan offers continuing

education courses. Most recently, the nurse-midwives had four hours of continuing

education. Health plan OB/GYNs, nurse practitioners, physician assistants, and

advice nurses will also be offered this program.

Cost

Staff of the Maternal/Child Health Lactation Program are not able to report on

costs of the program, partially because it is impossible to disaggregate the cost of

the breastfeeding promotion/support activities from the cost of the entire prenatal

education program. Some expenses include production/printing of the educational

materials, lactation consultant salaries, continuing education costs, and personnel

costs for perinatal community nurses.

Senior managers at Kaiser Health Plan of Georgia are in full support of the

Maternal/Child Health Lactation Program and provide ongoing budgetary support

for all components of the program.
48

Replicability

Kaiser Health Plan of Georgia representatives advise that health plans planning

to replicate this program must first have administration and staff commitment. The

program must be designed so that breastfeeding promotion is a concerted effort by

all staff who interact with pregnant women; it cannot be the responsibility of just

one person, or even just one type of provider. Pro-breastfeeding messages must be

laced throughout the prenatal program and be provided in different formats, including

print, video, didactic learning sessions (such as breastfeeding classes), and one-onone sessions with providers.

The midwifery component is very important. Nurse-midwives have been

providing care to pregnant women at Kaiser Health Plan of Georgia for almost a

decade. Enrollees have the choice of either an OB/GYN or a nurse-midwife. Even

in high-risk pregnancies, in which an OB/GYN must be involved, nurse-midwives

may co-manage the pregnancy. The nurse-midwives meet with all women during

the initial obstetric visit, whether or not an OB has been selected for prenatal care.

They are also at the hospital and provide immediate postpartum lactation support to

most women.

Lessons Learned

Staff have learned some important lessons that have led to changes in the

Maternal/Child Health Lactation Program. First, breast pump rental for women

with babies in the neonatal intensive care unit (NICU) was discontinued recently

after it became clear that the lack of a good system for tracking the pumps resulted

in the loss of pumps each year. Staff note that there are many ways for women in

Atlanta to rent breast pumps and so they did not feel this was a good use of health

plan resources.

Faced with consistently low attendance at daytime breastfeeding classes, staff

made the decision to discontinue those classes and focus instead on the evening

classes. However, despite being no cost to participants, the frequency of the class

offerings, and the geographic diversity of class locations, it is still a challenge to

encourage women to attend class. Kaiser Health Plan of Georgia staff believe that

the primary reason is that women’s lives are so busy. Therefore, the solution has

been to infuse breastfeeding messages throughout the prenatal care and educational

components of the program and to provide ample access to knowledgeable providers.

Directions for the Future

Staff of the Maternal/Child Health Lactation Program have several plans for the

future, including:

✹ Conducting an outcomes study to verify what they believe to be true about the

value of this program in improving breastfeeding rates among enrollees;

✹ Improving hospital practices, including having women see a nurse-midwife

soon after birth and helping hospital staff gain the knowledge and expertise

they need to support women who want to breastfeed;

✹ Expanding the breastfeeding components of all the educational materials; and

✹ Considering the reasons that so many women seem to stop breastfeeding after

the first few months and then designing services to support them in

continuing.
49

Health Plan Contact Information

Ann Weathersby, MSN, CNM

Assistant Manager, OB/GYN

Kaiser Health Plan of Georgia

Nine Piedmont Center

3495 Piedmont Road, NE

Atlanta, GA 30305-1736

Tel: (770) 496-3421

Fax: (770) 496-3424

E-mail: annmw@mindspring.com

Jamie Ray, RN, CCE, IBCLC

Maternal Child Health Education Supervisor

Kaiser Health Plan of Georgia

Nine Piedmont Center

3495 Piedmont Road, NE

Atlanta, GA 30305-1736

Tel: (770) 496-3676

Fax: (770) 496-3424

E-mail:jamie.ray@kp.org
50
51

Case Study V—Kaiser Permanente Northwest

(Portland, OR)

The Mother-Baby Program

Program Development

and Implementation

Overview

Kaiser Permanente Northwest has

been educating members and providers

about the health benefits of

breastfeeding for more than 10 years.

The health plan’s innovative program

incorporates prenatal education,

inpatient lactation support, and

outpatient lactation consultation

services, forming a comprehensive

approach to breastfeeding promotion

that spans a woman’s pregnancy, birth, and postpartum care. In addition, through

staff education efforts, Kaiser Permanente ensures that the health plan’s strong

commitment to breastfeeding promotion is demonstrated in all member services.

Background

In the mid-1980s when post-birth length of stay was at a minimum and new

mothers were requesting discharge as early as 12 hours after birth, pediatricians at

Kaiser Permanente Northwest expressed concern about the medical wellbeing of

newborns. As is standard, a follow-up visit did not occur until two weeks after the

baby’s birth. This made it difficult to promote breastfeeding, as a new mother might

abandon the attempt before the first doctor’s visit.

At the same time, research about the health benefits associated with breastfeeding

for both mother and newborn was gaining prominence. Kaiser Permanente’s first

lactation consultant helped establish the health plan’s lactation support services

and breastfeeding education. The newly-created Mother-Baby program was added

to routine postpartum care. It brings mother, baby, and family back to the hospital

within three days of discharge to monitor feeding techniques, with an emphasis on

breastfeeding, and answer any questions new parents may have.

In 1992, Kaiser Permanente Northwest applied for the World Health

Organization’s (WHO) letter of intent to become “Baby Friendly,” and in January

2000, became one of only two dozen hospitals in the United States to earn the

official designation.

Founded in 1945, Kaiser Permanente is

a nonprofit, group-practice health

maintenance organization (HMO) with

headquarters in Oakland, California.

Kaiser Permanente serves the health care

needs of members in 11 states and the

District of Columbia. It encompasses

Kaiser Foundation Health Plan, Inc.,

Kaiser Foundation Hospitals, and the

Permanente Medical Groups. Kaiser

Permanente Northwest serves more than

450,000 people in Northwest Oregon and

Southwest Washington, and provides

dental care to about 185,000.
52

Goals

Kaiser Permanente’s goals are to educate the mother-to-be and new mother, to

educate providers so that they can answer questions and offer support, and, most

importantly, to support the new mother to help her be successful at breastfeeding.

Target Population

All pregnant enrollees are targeted for Kaiser Permanente Northwest’s

breastfeeding program. The first visit after a woman informs the health plan she is

pregnant is a group childbirth class. Breastfeeding is highly encouraged during this

initial visit and in all educational efforts throughout the pregnancy.

All literature is designed to be culturally sensitive. The program also encourages

breastfeeding in minority populations by offering educational materials in Russian,

Spanish, and Vietnamese and by ensuring that the bilingual instructors for the Russian

and Spanish childbirth classes understand cultural as well as lactation issues.

Lactation telephone counseling is also available through an interpreter. A prenatal

clinic offered for teens includes a breastfeeding education component.

Essential Program Elements

Prenatal Breastfeeding Classes

The health plan begins educating pregnant women about breastfeeding from the

initial prenatal visit and continues to reinforce the health benefits through postpartum

follow-up. Newsletters provided during preparation for childbirth classes reinforce

the health benefits of breastfeeding to both mother and baby. In addition, the fifth

class in the six-class series concentrates exclusively on providing information to

parents about feeding options. This class strongly emphasizes the importance of

breastfeeding and includes such areas as benefits, anatomy/physiology, positioning,

social issues, sexuality, support systems, and breastfeeding resources. A class

specifically devoted to breastfeeding for working mothers is also offered.

Inpatient Lactation Support

Kaiser Permanente Northwest’s Sunnyside Hospital offers full inpatient lactation

support. When the mother is admitted to the hospital prior to birth, she is given a

packet of information that includes detailed information about breastfeeding. Closed

circuit television available in her room also includes video presentations about

various postpartum topics, including breastfeeding. All mothers are visited after

birth by International Board Certified Lactation Consultants (IBCLCs) to allow

breastfeeding issues to be identified and corrected early on. It is important to note

that in all prenatal and postpartum contact with mothers, educators and nurses ask,

“Will you be breastfeeding?” rather than offering the option of formula-feeding.

Staff certainly do not criticize or offer diminished services for those mothers electing

to formula feed, but rather strive to encourage breastfeeding in all contacts with

members.

Newborns stay in the room with mothers after birth and rocking chairs and sofas

provide comfortable positioning for breastfeeding. Private rooms and breast pumps

are available in the nursery for mothers whose babies require special attention.

Maternity ward nurses provide additional support and assist with breastfeeding

technique.
53

Mother-Baby Program

While the mother and baby are still in the hospital, an outpatient lactation

consultant schedules return visits for mothers, babies, and family members within

three to five days after birth. In some non-Kaiser facilities, although hospital staff

provide inpatient support, a Kaiser Permanente nurse individually visits each Kaiser

Permanente patient to personally schedule her follow-up visit and invite her to

participate in the Mother-Baby Program.

The one-on-one outpatient meeting with a board-certified lactation specialist is

scheduled for one hour. During this time, the lactation consultant conducts a physical

assessment of the baby, verbal assessment of the mother, and a breastfeeding

assessment to observe the mother’s technique and identify problems early on.

Additional follow-up visits are scheduled if necessary.

Participation in the Mother-Baby Program is not exclusive for breastfeeding

mothers. All mothers are invited to participate and an overall feeding and baby

assessment is conducted. In fact, this initial outpatient visit has been accepted to

qualify for the well-child visit measure for the National Committee on Quality

Assurance’s (NCQA) Health Plan Employer Data and Information Set (HEDIS).

Lactation consultants offer appointments and are available for telephone consult

seven days a week. A breastfeeding hotline is also available.

Breast Pump Rental or Purchase

Resources for breast pump rental or purchase are available to guide mothers to

quality equipment. Vendors who provide pump rentals offer discounts to Kaiser

Permanente members. In fact, those Kaiser Permanente members whose employers

have included durable medical equipment coverage in their benefits package and

who require a breast pump because of medical reasons may rent or purchase a

breast pump under the coverage. Additionally, those who are returning to work

after birth may qualify for similar coverage.

Staff Education

In addition to the expertise of lactation consultants who come into contact with

mothers and their newborns on a daily basis, Kaiser Permanente requires

breastfeeding education for all new inpatient hires-from new staff physicians to

clerical staff who come into contact with members through telephone appointment

bookings. This ensures that every Kaiser Permanente staff member is aware of the

health plan’s commitment to and promotion of breastfeeding. The health plan also

offers coordinated training for nurses who want to become certified lactation

consultants.

Evaluation and Outcomes

Evaluation

Kaiser Permanente Northwest is able to track the success of its breastfeeding

program through its electronic medical record system, EpicCare, which captures

detailed information about each mother’s visit. Descriptive information fields within

this specialized system allows detailed information for all mothers and babies to be

captured both prenatally and postpartum. Nurses and physicians can also be prompted

by the system to conduct necessary follow-up.
54

Outcomes

Overall assessment demonstrates high patient and physician satisfaction with

Kaiser Permanente Northwest’s breastfeeding program. In 1999, 3,342 mothers

(about 60% of pregnant members) participated in Kaiser Permanente’s prenatal

class series, including those mothers who have given birth before. Over 90% of

new mothers participate in lactation follow-up with the Mother-Baby Program.

Currently, nearly 90% of mothers who deliver at Kaiser Permanente Northwest

facilities or contracted hospitals breastfeed at discharge, compared to 60% in 1995.

Kaiser Permanente has also noticed improved health of breastfed babies as shown

by decreased readmits and transfers. Mothers who breastfeed are likewise healthier.

Cost

Total annual expenses for the Mother-Baby Program, including the follow-up

well-child visit with a certified lactation consultant and all lactation support services,

are less than $400,000 for approximately 5,000 births per year. In working with

contracted hospitals that are non-Kaiser facilities, expenses incurred, such as those

associated with predischarge visits by Kaiser Permanente staff, are necessary to

ensure the success of the health plans’ breastfeeding promotion program. In addition,

because Kaiser Permanente no longer accepts donations of free formula, it incurs

an annual expense of approximately $30,000 for formula when it is medically

necessary for supplemental feeding. Although many aspects of Kaiser Permanente

Northwest’s breastfeeding initiative are cost intensive, return on investment is

evidenced in decreased readmissions and office visits for illness and lactation

concerns.

Replicability

Facilitators of Kaiser Permanente Northwest’s breastfeeding program recommend

that, to be successful, any similar initiative in another health plan would require a

physician and non-physician champion to serve in leadership roles. The key to

overall program success is consistent research-based provider education to gain

physician and nurse buy-in and coordination of the efforts of all caregivers, especially

in non-group model health plans. Kaiser Permanente believes that it is important to

ensure that all employees actively support the health plan’s commitment to

breastfeeding promotion.

Lessons Learned

When Kaiser Permanente closed its Best Kaiser Hospital in 1996 and decided to

contract with three other non-Kaiser hospitals in addition to Kaiser’s Sunnyside

facility, Senior Neonatologist Gunnar Waage, MD recognized the difficulties the

health plan would encounter in coordinating care in non-Kaiser facilities. While the

health plan could exact control over staff actions at its own Sunnyside Hospital,

gaining the cooperation of independently contracted hospital staff could be a

challenge.

In answer to this challenge, Dr. Waage initiated the development of a Neonatal

Committee to coordinate services among facilities. This committee is comprised of

a physician representative from each facility with which Kaiser Permanente contracts,

OB/GYNs and pediatricians, the chief of pediatrics, and the pediatric subspecialities

service manager. Kaiser Permanente’s commitment to the promotion of breastfeeding
55

is embedded in a long-term program. Despite the retirement and departure of initial

program champions, the Mother-Baby Program flourishes.

Another difficulty Kaiser Permanente Northwest encountered was formula

company’s marketing strategies to encourage formula use through the distribution

of gift bags to new mothers. Kaiser Permanente eliminated this distribution in their

Sunnyside Hospital and works to ensure that members who give birth at non-Kaiser

facilities do not receive these promotional packages.

Directions for the Future

In keeping with the American Academy of Pediatrics’ recommendation to

continue breastfeeding for the first year of life and in recognizing that breastfeeding

methodologies change when babies begin solid foods, Kaiser Permanente will begin

to offer a two-hour class about solid feeding and the changes in breastfeeding that

will occur when solid feeding is initiated. This education will include a

recommendation to delay the introduction of solid foods until six months.

In addition, Kaiser Permanente will continue to encourage staff nurses to become

certified lactation consultants to increase their level of expertise and allow for

increased coordination of care. Kaiser Permanente’s on-site research capacity will

continue to identify barriers to breastfeeding and strategies to remove them.

Health Plan Contact Information

Carol Tracy

Maternal and Women’s Health Coordinator

Kaiser Permanente Northwest

10180 SE Sunnyside Rd.

Clackamas, OR 97015

Tel: 503-571-6185

Fax: 503-571-2671

E-mail: Carol.Tracy@kp.org
56
57

Case Study VI—Kaiser Permanente

Southern California

(Pasadena, CA)

Lactation Promotion

Program Development

and Implementation

Overview

Kaiser Permanente Southern

California’s integrated health delivery

system allows the health plan to

emphasize the importance of

breastfeeding through services provided

across a woman’s pregnancy. From

prenatal education through postpartum

assessment, and through inpatient care

and outpatient services, the health plan’s program to encourage breastfeeding offers

a wide-range of services. Medical Centers offer many, if not all, of the following

options: prenatal education classes, inpatient lactation consults following birth,

group-setting postpartum lactation clinics and support groups, individualized

outpatient problem-solving appointments, a 24-hour breastfeeding information line,

and breast pump rental and purchase. In supporting such a wide geographic area,

the various Medical Centers that compose Kaiser Southern California uniquely tailor

program components to meet the specific needs of the diverse racial and ethnic

populations each serves.

Background

Kaiser Permanente Southern California realized in the early 1980s that a

breastfeeding program targeted to new mothers could encourage improved health

of members. Needs assessments conducted at various Medical Centers demonstrated

excellent breastfeeding initiation rates followed by dramatic decreases within the

first two weeks. Breastfeeding initiation rates dropped as much as 26% between the

time of hospital discharge and the first scheduled newborn visit. In addition, the

health plan realized significant use of urgent care, visits to the emergency room,

and contact with advice nurses in the early postpartum period. Between 35-56% of

patients visited their doctor prior to the first scheduled newborn visit and up to 60%

sought phone advice within 60 hours of discharge. A 1.5% readmission rate for

preventable problems existed despite feelings that this could be reduced with early

follow-up and intervention. Also, patients complained that caregivers in inpatient

and outpatient care settings provided inconsistent information.

Caregivers also recognized that with the busy hospital stay following birth, there

was limited time to reinforce prenatal education, observe breastfeeding, and teach

patients what to expect.

Founded in 1945, Kaiser Permanente is

a nonprofit, group-practice health

maintenance organization (HMO) with

headquarters in Oakland, California.

Kaiser Permanente serves the health care

needs of members in 11 states and the

District of Columbia. It encompasses

Kaiser Foundation Health Plan, Inc.,

Kaiser Foundation Hospitals, and the

Permanente Medical Groups. Kaiser

Permanente Southern California provides

health care services to 2.9 million

members.
58

Formal programs to address these concerns and promote breastfeeding started

in Kaiser’s San Diego, Sunset, and Fontana facilities in the early 1980s, with other

Medical Centers to follow until all Kaiser Permanente Southern California facilities

had initiatives in progress. In 1988, the health plan developed a regional consensus

statement on principles of perinatal care, with breastfeeding as one of the major

foci. In the early 1990s, Kaiser’s progress gained more momentum when the

American Academy of Pediatrics’ (AAP) and the State of California issued guidelines

which required access to medical personnel in the early days after discharge. It is in

those early days that lactation support is so crucial. In early 1998, local coordinators

of breastfeeding programs at the various facilities began to meet to share information

and to develop consensus on methodologies addressing breastfeeding concerns.

Goals

Although each Medical Center is under the auspices of the Kaiser Permanente

Southern California health care system, each center addresses breastfeeding concerns

in a unique way to best meet the healthcare needs of its population. In general,

however, each initiative strives to:

✹ Meet or exceed Healthy People 2010 goals for breastfeeding initiation and

increase breastfeeding duration (including educating, assisting, and supporting

working mothers to continue breastfeeding after return to work);

✹ Improve utilization of a clinic devoted exclusively to postpartum follow-up

and breastfeeding issues, rather than use of emergency room or urgent care

facilities;

✹ Decrease hospital readmission rates; and

✹ Improve patient satisfaction by increasing continuity of care and consistency

of information given to new patients.

Target Population

Kaiser Permanente Southern California’s breastfeeding initiatives are targeted

to and available for all newly delivered mothers. Special attention is devoted to

pregnant teens through special teen OB clinics. In addition, the health plan is

committed to providing culturally competent care and education in all areas,

including this one. Therefore, Kaiser offers region-wide training for all caregivers,

including a class devoted exclusively to educating providers about varying cultural

beliefs surrounding breastfeeding. Challenges such as health beliefs, family

hierarchy, learning styles, and privacy issues are addressed to educate providers

and nurses about providing culturally competent care.

Each Medical Center serves a unique composition of racial and ethnic groups.

Educational programs, classes, and services are developed to meet specific needs

of the community. For example, to serve the breastfeeding needs of the Latino

membership (over 40% in some areas), Kaiser provides culturally and linguistically

appropriate educational materials in Spanish. Rather than providing direct translation

of information, care is taken to translate into a conversational terminology specific

to each culture. Readability is aimed at a fifth grade reading level to help ensure

comprehension. Interpreters are utilized whenever possible to ensure clear and

concise communication and understanding. In addition, the health plan has realized

that some ethnic groups prefer hearing or viewing educational materials rather than

reading them. To ensure the learning needs of the various ethnic populations are
59

being met, the health plan offers a toll-free, 24-hour a day, seven days a week

recorded health phone message service. Breastfeeding education videos are also

available for loan from an extensive video library.

Essential Program Elements

Prenatal Education

The health plan offers no-cost local prenatal class series for members every four

to eight weeks, depending on the facility. Breastfeeding is integrated into these

classes, which address the entire continuum of care for the prenatal mother. The

series is offered in Spanish in many Medical Centers and can be specifically targeted

to teen mothers in the Teen Pregnancy Clinic. Prenatal information sheets and packets

provide information about various aspects of pregnancy and childbirth, including

advantages and tips about breastfeeding.

Inpatient Lactation Support

Many Kaiser hospitals provide lactation consultants or educators to offer handson lactation support and education on basic management techniques to postpartum

women. Specialized information, referral, and support are provided when

breastfeeding problems are encountered. Some Medical Centers offer an inpatient

mother’s class that includes breastfeeding instruction and information.

Postpartum Outpatient Support

The “Great Starts” Mother-Baby Follow-up Program, also referred to as

“Breastfeeding Clinic” or “Lactation Clinic” in other Medical Centers, is a service

open to all mothers and babies during the first days after discharge. Appointments

are booked prior to hospital discharge or within 24-48 hours of discharge by phone.

In addition to general medical assessment of the newborn and mother during the

one-hour consult, all clinics provide breastfeeding assessment along with assessing

newborn hydration status; evaluation for breastfeeding effectiveness; and correction

of inefficient or incorrect suckling. Depending on facility, the clinics are operated

five to six days per week and many Medical Centers do assessment/evaluation over

the phone when patients do not schedule in-person appointments.

Kaiser Permanente Southern California also offers one-on-one lactation support

to mothers who are experiencing difficulties with breastfeeding. Referral or

coordination of services with pediatricians and/or OBs is arranged as needed when

evaluation does not meet established norms. A care plan is developed for each specific

situation with follow-up until breastfeeding problems are resolved. Approximately

20-25% of all babies and mothers are seen more than one time.

At many facilities, a breastfeeding support group offers weekly or monthly

information and support to new parents during the early months of parenting. Some

programs include education on many basic parenting issues as well as breastfeeding

services. In addition, breastfeeding and returning to work/school classes teach

mothers how to maintain a milk supply when they need to be separated from their

baby on a regular basis.
60

Breastfeeding Information Line

Kaiser Southern California also offers an automated breastfeeding information

telephone line 24 hours a day/seven days per week. Up to 20 of the most commonly

asked questions about breastfeeding are addressed in areas such as mother concerns,

infant concerns, milk supply problems, dietary concerns, and breast pump

information.

Breast Pump Rental Services

Kaiser offers reduced rates for breast pump rental or purchase through its Medical

Center Health Stores. In addition, mothers participating in Medi-Cal (California’s

Medicaid system) or who have coverage for durable medical equipment enjoy breast

pump provision as a covered benefit when the baby cannot breastfeed or the mother

has complications that affect breastfeeding.

Provider Education

At least annually, providers attend in-services on the latest research, current

practices, policies, and programs in breastfeeding. In addition, they attend classes

about cultural diversity issues,

Evaluation and Outcomes

Evaluation

Kaiser tracks improvements in breastfeeding rates, utilization rates, and patient

satisfaction through patient surveys and chart review. The Woodland Hills facility

has established a lactation support database to capture prenatal information,

postpartum assessment about mother and child as provided through outpatient

lactation support, as well as tracking of advice nurse inquiries. This database is

accessible across the entire health plan’s area network.

Outcomes

Kaiser Southern California has observed significant improvements in

breastfeeding initiation and long-term breastfeeding rates since the inception of

their health plan-wide focus on breastfeeding. Currently, 64-87% of mothers are

breastfeeding at hospital discharge and 61-77% are breastfeeding at two weeks.

The Panorama City facility has studied long-term breastfeeding rates for three

consecutive years, starting from the year prior to the initiation of a breastfeeding

clinic through the first two years of clinic operation. Their results are on the next

page.
61

Long-Term

Infant Age Breastfeeding Rates Improvement

2 weeks 1997 - 54% 20% breastfeeding rate

1998 - 61% increase in three years

1999 - 74%

2 months 1997 - 33% 23% breastfeeding rate

1998 - 42% increase in three years

1999 - 56%

 4 months 1997 - 22% 18% breastfeeding rate

1998 - 27% increase in three years

1999 - 40%

 6 months 1998 - 17% 13% breastfeeding rate

1999 - 30% increase in two years

In addition to improvements in breastfeeding rates, Kaiser Permanente Southern

California has also observed reduced hospital readmission rates (the most dramatic

being a decrease from 1.5% per year to .5%) and reduced clinic utilization.

Cost

The resource intensity of Kaiser’s breastfeeding initiative is low. One estimate

put start-up costs for the program at approximately $56,000, but most of the programs

have developed out of grassroots efforts. Facility costs are negligible because existing

medical center space is utilized. Maintenance costs for one facility are estimated at

$65,000-$85,000 per year. It is also estimated that in the first year of operation,

Kaiser saved $91,000 by reducing unscheduled emergency room visits. Long term

return on investment translates into healthier babies, children, and mothers and

increased patient satisfaction.

Replicability

Kaiser Permanente Southern California has already demonstrated the replicability

of its breastfeeding initiatives within the region it serves. Since the early 1980s

when only three of the Medical Centers originally initiated breastfeeding programs,

all of the Medical Centers have adopted similar programs with variations to cater to

the specific healthcare needs of the populations they serve.

Program administrators believe that the success of a similar program in another

healthcare setting necessitates firm health plan dedication to the importance of

breastfeeding, determination to hire well-trained and dedicated staff to operate and

guide the program, and ongoing member and provider education.
62

Lessons Learned

Kaiser Permanente Southern California has learned a great deal during the

development, implementation, and continuous quality improvement of its

breastfeeding initiative. In response to observed outcomes, the health plan made

some enhancements to continue to meet its membership needs. Motivating mothers

to return to the Medical Center for outpatient lactation consultation soon after

delivery has been a challenge. To address this, some centers added inpatient lactation

support. Other centers increased access to the outpatient breastfeeding clinics by

increasing hours of operation or days of coverage.

Another difficulty encountered has been the newness of the lactation consultant

field as an integrated part of mainstream American medicine. This has resulted in a

variation in skill levels and scope of practice between lactation consultants. A

lactation consultant website was created to facilitate better sharing of resources and

knowledge between disciplines and medical centers. In addition, a Southern

California Lactation Consultant Committee, comprised of representatives from all

the facilities, held its first meeting in November 2000.

Kaiser also began working with formula manufacturers in the mid-1990s to meet

competing needs of both parties. The formula manufacturer agreed to provide

“breastfeeding support bags” to those mothers who have decided to breastfeed. The

company includes water bottles and breast pads for the mother instead of baby

bottles and coupons for formula. The one concession the health plan had to make to

continue the relationship, however, was the inclusion of a four-ounce container of

powdered milk with a label advising mothers to consult a physician prior to use.

This product is the only item in the package that promotes formula-feeding. Likewise,

Kaiser avoids distributing literature that advertises pharmaceutical products and

educates families about marketing ploys in prenatal classes.

The health plan acknowledges that the group/staff model makes it easier to

identify and follow patients and optimize resources. The critical components of

Kaiser Southern California’s approach are the integration of breastfeeding services

to follow mothers from the prenatal through the postnatal experience; the integration

of services across disciplines to ensure consistent information and support; and the

inclusion of education, support, and hands-on teaching in breastfeeding promotion

and encouragement.

Kaiser Permanente Southern California makes the following specific

recommendations to a health plan seeking to implement a similar program:

✹ Plan Well. During initiation phase, involve key players in the design of the

program;

✹ Secure support and referrals from health care providers discharging mothers

and babies to home;

✹ Design prenatal education components that complement and support the

inpatient component while continuing to refer to outpatient support services;

✹ Facilitate open communication between all staff members, with quarterly staff

meetings of all involved members to adjust and fine-tune all programs;

✹ Frequently review any educational materials being disseminated to patients

for cohesiveness;
63

Health Plan Contact Information

Judy Collier, RNC, MSN

Senior Perinatal Nurse Consultant

Patient Care Services, Seventh Floor

Kaiser Permanente

393 East Walnut

Pasadena, CA 91188

Tel: (626) 405-6052

David Braun, MD

Regional Coordinator, Perinatal Services

Clinical Services, Seventh Floor

Kaiser Permanente

393 East Walnut

Pasadena, CA 91188

Tel: (626) 405-5611

✹ Design or use an existing database for outcome and statistical tracking

purposes; and

✹ Review the quality of service of the program for risk management and quality

improvement opportunities.

Directions for the Future

Kaiser Permanente Southern California hopes to utilize a consistent data collection

tool in the future so that all programs collect the same information and enter it into

a regional database to be used by all medical centers. Facilities will continue to

share information and lessons learned through the Southern California Lactation

Consultant Committee. In addition, Kaiser hopes to provide outpatient coverage

seven days a week, if necessary, to ensure that mothers and babies have access to

the information and support they need.
64
65

Case Study VII—Keystone Health Plan East

(Philadelphia, PA)

Baby BluePrints/Baby FootSteps

Program Development

and Implementation

Overview and Goals

Baby BluePrints (or Baby Footsteps as the

program is called outside Pennsylvania), is a

comprehensive perinatal program including

prenatal risk assessment, information

dissemination, case management, and

postpartum services for at-risk mothers and

newborns. The program includes a strong emphasis on breastfeeding education and

support for all pregnant members. Specific breastfeeding promotion activities include

prenatal education about breastfeeding, partial reimbursement for lactation classes

and breast pump purchase, postpartum lactation consultations (including in-home

visits), no-cost rental of electric breast pumps for medical necessity, and referrals to

community resources.

Keystone Health Plan East’s goal for breastfeeding promotion is “to inform

women about the benefits of breastfeeding and to support those who decide to do

so, without in any way making formula-feeding mothers feel guilty for making that

choice.”

Background

Promotion of breastfeeding has always been a part of Baby BluePrints/Baby

Footsteps. The program began in June 1993 with Keystone Health Plan East’s HMO

population, after it was launched earlier in the indemnity product of Independence

Blue Cross (Keystone’s parent company). At that time, two well-respected

perinatologists worked with Plan nurses to assess the interest of participating network

OB/GYNs in a “high-risk obstetrics program.” The nurses visited a number of OB/

GYN offices and gathered information about possible program components. A panel

of Keystone OBs approved the eventual design. This OB panel has been maintained

and continues to oversee the program and vote on any changes. The program was

first offered to the PPO population in 1994.

Between 1994 and 1996, when the program was gaining momentum, Plan

network staff visited many physicians’ offices to explain the program individually.

Program staff and Medical Director also provided formal presentations about the

program at participating hospitals’ OB/GYN department meetings and at formal

Plan annual OB/GYN office staff updates. These presentations were supplemented

with educational materials mailed to OBs, including newsletter articles and special

mailings. In later years, in order to create additional opportunities for the

identification of program participants, staff have provided education to Keystone’s

Keystone Health Plan East is an IPA

model HMO offered by Independence

Blue Cross (IBC), a member of the Blue

Cross and Blue Shield Association. IPC

also offers PPO and indemnity

products and serves a total of 4.5

million members in southeastern

Pennsylvania, as well as in regional

and national markets through

subsidiaries and affiliates.
66

pre-certification and concurrent review staff. As a result, those staff members have

gained heightened awareness about the need to refer women who have been

hospitalized or who have complications identified during an office visit to the

program. Input from providers is fostered through a variety of ongoing activities,

including quarterly OB panel meetings and with the OB office managers advisory

group.

The program has changed over time. In the beginning, registration was voluntary

and fewer than 50% of eligible mothers were enrolled. After several iterations of

the registration process, the health plan changed focus and began to tie program

registration to preauthorization for prenatal care. Linking program registration to

preauthorization came about initially through Keystone’s Medicaid program. Relying

on Medicaid members to sign up would have yielded extremely low numbers, so

the health plan was challenged to devise a method for identifying eligible women

through a passive process. The solution was to use preauthorization as a way to find

those women. This proved so useful that the health plan has since expanded it to the

commercial population as well. The improved process has increased program

participation to 92% of eligible mothers.

While Keystone Health Plan East served the Medicaid population in the mid1990s, the health plan transferred its Pennsylvania Medicaid business to another

subsidiary, which is independently managed. The staffs of the two health plans

cooperate extensively on their prenatal case management programs, sharing expertise

and experience.

The Baby BluePrints/Baby FootSteps program has become more systematized

over time, with the creation of detailed written protocols. These reflect the input

and approval of the Plan’s OB advisory committee, a group of network perinatologists

and generalist obstetricians representing all geographic areas and practice types of

the tristate business area (Pennsylvania, New Jersey, and Delaware).

Target Population

The target population for this program is all pregnant women who are members

of the commercial HMO and PPO lines of business, and at-risk traditional business

subscribers. The plans have more than 30,000 births each year and more than 80%

of mothers are enrolled in the program.

Essential Program Elements

Identification of Eligible Members and Invitation to Participate

At their first prenatal visit, all women fill out a detailed questionnaire which is

forwarded to the Baby BluePrints/Baby Footsteps staff within 30 days of a confirmed

pregnancy test. A perinatal a nurse case manager screens the questionnaire for risk

according to an algorithm approved by the OB committee. Clerical staff data enter

clinical information into the case management database and administrative

information into the utilization management database for the delivery admission.
67

Program Components for Low-Risk Pregnancies

The essential program elements vary for low-risk and high-risk pregnancies.

Women with normal, low-risk pregnancies:

✹ Receive educational mailings, including a copy of the commercially-available

book, What to Expect When You Are Expecting, and a tri-fold card produced by

Baby BluePrints/Baby Footsteps that highlights important topics, including

nutrition and breastfeeding;

✹ Receive a phone call from a program staff member with a follow-up

questionnaire at 28 weeks gestation to ascertain any change in risk status;

✹ Have access to a 24-hour telephone service that is answered by a nurse during

business hours and is staffed by an answering service that connects to an oncall nurse during off hours;

✹ Are eligible for partial reimbursement for any antepartum class, including

breastfeeding classes ($40 per member) and battery or manual breast pump

purchases ($100 per member);

✹ Can access lactation consultants after delivery and are referred to community

resources; and

✹ Will be provided rental of a heavy-duty electric breast pump for as long as

medically necessary if they or their babies develop a medical problem that

requires the use of a pump.

Program Components for High-Risk Pregnancies

For high-risk pregnancies, the list of services includes all of the above, plus

comprehensive case management by the program’s experienced perinatal nurse case

managers. Services are initiated when the case manager assesses the pregnant

member to be at risk for pregnancy complications via formal risk assessment, hospital

admission, or a phone call from the obstetrician or the patient herself. The case

manager contacts both the member and the woman’s obstetrician. The goal is for

physician and case manager to work together to provide the expectant mother with

optimum support and services. If necessary, a wide range of assistance and resources

can be utilized, including:

✹ Skilled nursing visits (and provision of IV fluids, total parenteral nutrition

[TPN], and medications at home) by nurses who have at least three years of

perinatal experience;

✹ Consultations with registered dietitians;

✹ Visits by home health aides to offer additional home care support (for

example, if the mother is on bedrest and there is no other way to assist her);

✹ Regular telephone contact with the nurse case manager;

✹ Referrals to relevant social service and community agencies, as appropriate;

and

✹ Provision of durable and disposable medical equipment as required.

Each member is assessed initially and again at 28 weeks through a formal risk

assessment form. The initial form is generally completed by the patient at her first

obstetrical visit. The second is administered telephonically by Baby BluePrints/

Baby Footsteps staff members.
68

Mother’s Option Program

In addition, all mothers have the opportunity to participate in the Mother’s Option

program. Through this program, women whose vaginal delivery and postpartum

recovery are uneventful are given the choice of staying in the hospital for two days

or going home after one day and receiving two home visits—one 24 hours after

discharge and the second 72 hours after discharge. The second postpartum visit

provides an excellent opportunity for the home health nurse to provide assistance

with breastfeeding. All of the home health nurses are Registered Nurses (RNs) and

are specialists in maternal and child health. Women who have had a Cesarean section

have the choice of spending four days in the hospital or leaving after three days and

receiving a visit 24 hours post discharge. Additional visits are authorized as medically

necessary. Lactation consult is also available with IBCLC (International Board

Certified Lactation Consultants) certified registered nurses.

If the baby has jaundice and requires phototherapy, Independence Blue Cross

will provide the therapy at home upon request of either the pediatrician or hospital.

A home health nurse will set up the equipment, teach the family how to use it, draw

bloods for bilirubins, and will return for visits as needed. By keeping the baby at

home, it is easier for the mother to continue regular breastfeeding.

In an effort to serve its diverse member population, Keystone provides translator

services for telephone calls and home visits. Languages covered include Chinese,

Russian, Vietnamese and several dialects of Spanish.

Evaluation and Outcomes

The Baby BluePrints/Baby Footsteps program has computer systems that use

claims information to generate automatic operations reporting. The system also

includes demographic risk information that makes it possible for Keystone research

and evaluation staff to evaluate the program. Two separate studies have demonstrated

a dramatic drop in the number of OB medical days (admissions without deliveries)

since the inception of the program. High-risk women are being maintained in the

home and not at the hospital. While no studies have focused exclusively on

breastfeeding rates, in the future, the program plans to track use of breast pump

reimbursement and compare it with the demographic and outcomes data to

understand who is breastfeeding and focus efforts on populations who are not.

Cost

Program staff report that the Baby BluePrints/Baby Footsteps program is a

resource intensive program, but cannot give a specific per/member cost because of

the difficulty in evaluating the multiple systems of care involved in the program.

Anecdotally, staff report cost effectiveness on a case-by-case basis, but they have

not yet been able to capture costs to demonstrate savings on a system-wide basis.

Data are forthcoming on the cost of breast pump rentals and reimbursements to the

health plan.

Replicability

According to program staff, components of the Baby BluePrints/Baby Footsteps

program important for replication in other health plans include commitment from

health plan administration, in-house knowledge and expertise, ability to “sell” the

program to network physicians, hospitals, and staff; and the availability of many
69

perinatal home care agencies and lactation consultants in the area with which to

contract.

Lessons Learned

One of the major lessons learned involved the breast pump reimbursement

program. Initially there were some difficulties with paying the claims when the

program was introduced to the PPO population. Whereas when the program was

just available to HMO members, all those members had to do was buy a pump from

an approved pharmacy and get reimbursed. When the program was rolled out to

PPO members, however, they were told to buy their pumps from the plan’s durable

medical equipment (DME) companies. Unfortunately, the health plan then learned

that the DME did not supply breast pumps. To solve this problem, the health plan

changed the policy so that PPO members can also buy the pumps at approved

pharmacies and still receive reimbursement.

Another challenge was that the health plan built demand for breast pumps and

lactation consultants but then the supply of both was too limited to meet the need.

Program staff suggest, “survey your equipment vendors and also know who and

where the lactation consultants are. You may need to give both the vendors and

lactation consultants a heads-up before the program is implemented.”

Independence Blue Cross serves a widespread geographic area that includes

some areas that do not have lactation consultants or supplies of breast pumps. As a

result, the plan’s nurses have had to give a great deal of telephone support to women

in those areas and have also searched the network to find pumps for these members.

Directions for the Future

The health plan is exploring whether to partner with vendors that can provide a

good selection of pumps at a discounted rate to solve some of the problems related

to breast pump availability.

In order to address the growing concern about food allergies in children, program

staff are adding information about the scientific basis for recommending

breastfeeding in all Baby BluePrints educational materials.

In addition, program staff are beginning to work with Keystone Health Plan

East’s healthy lifestyles employer partner program to disseminate information to

employers about the benefits of breastfeeding and why it is important to make it

possible for employees to express and store breast milk during the day.

Cathy Dratman, MD

Medical Director

Keystone Health Plan East

1901 Market Street

Philadelphia, PA 19103

Tel: (215) 241-3043

Fax: (215) 241-2878

E-mail: cathy.dratman@ibx.com

Margaret Ryan-Cook, RN

Manager, Prenatal Programs

Keystone Health Plan East

1901 Market Street

Philadelphia, PA 19103

Tel: (215) 241-3043

Fax: (215) 241-2878

E-mail: margaret.ryan-cook@ibx.com

Health Plan Contact Information
70
71

Case Study VIII—UCare Minnesota

(Minneapolis, MN)

Breastfeeding Promotion Program

Program Development

and Implementation

Overview

The success of UCare Minnesota’s

Breastfeeding Promotion Program is

based on the development of strong

community partnerships with state and

local public health agencies, as well as

implementation of health plan policies to

provide support for mothers who

breastfeed. The health plan has

demonstrated a strong commitment to

community support for breastfeeding by funding new and existing breastfeeding

promotion efforts. In addition, policy changes to increase access to breastfeeding

education, lactation support, and breast pumps demonstrate the health plan’s

dedication to breastfeeding support and encouragement among its membership.

Through this strategy, UCare Minnesota continues to increase awareness of the

benefits of breastfeeding, support mothers who choose to breastfeed, and promote

social support for breastfeeding in the community.

Background

In 1996, Ross Labs’ National Mothers Survey indicated that only 67.4% of

Minnesota mothers breastfed their infants in the hospital; the breastfeeding rate

decreased to 23.5% at six months after birth. In response to these startling findings,

the Minnesota Department of Health included two breastfeeding-related objectives

in its Public Health Improvement Goals for 2004:

✹ Increase the proportion of mothers who breastfeed their babies in the early

postpartum period to at least 75%; and

✹ Increase the proportion of mothers who continue breastfeeding until their

babies are aged five to six months to at least 50%.

UCare Minnesota was already aware of the mounting evidence indicating the

multiple health and economic benefits of breastfeeding for infants, mothers, and

society. The health plan also realized that breastfeeding rates were lowest among

low-income populations, younger mothers, recent immigrants, and some minority

populations.

Beginning in July 1998, UCare took a proactive approach to encouraging

breastfeeding within its membership and the community as a whole by initiating

the “Breastfeeding Promotion Program.” That same year, UCare partnered with the

Minnesota Department of Health (MDH) on its “Loving Support Makes

UCare Minnesota is a nonprofit, IPA

model health maintenance organization

serving more than 66,000 Minnesota

government program enrollees in 73

Minnesota counties. It was established

in 1984 by the Department of Family

Practice and Community Health at the

University of Minnesota Medical School.

The UCare provider network has grown

to include 468 primary care clinics, 125

hospitals, and 10,000 providers. UCare

Minnesota is now the fourth-largest

HMO in Minnesota.
72

Breastfeeding Work” campaign and met with representatives of other local public

health organizations to discuss strategies for collaboration. UCare Minnesota’s

resulting initiative provided financial support to build on programs implemented

by partner agencies, and also included health plan-specific interventions, including

prenatal education and breastfeeding promotion; postpartum assessment and followup care; and improved access to breast pumps.

Target Population

It is UCare Minnesota’s belief that community support for breastfeeding will

increase initiation and maintenance rates overall. For this reason, the educational

components of the health plan’s Breastfeeding Promotion Program are targeted to

all Minnesota residents, with particular emphasis on pregnant Medicaid enrollees

and their families. UCare has also provided funding for a breastfeeding intervention

targeted specifically to the Hmong population in Minnesota.

Goals

The goal of UCare Minnesota’s Breastfeeding Promotion Program is to promote

breastfeeding among members through increased awareness of the benefits of

breastfeeding, improved access to breast pumps as needed, and promotion of social

support for breastfeeding mothers.

Essential Program Elements

With the realization of the positive benefits of breastfeeding and the MDH’s

emphasis on breastfeeding promotion, UCare Minnesota sought ways to incorporate

breastfeeding education and promotion into existing member services, as well as

strategies to contribute to other public health agencies’ efforts.

Member Services

✹ Prenatal Breastfeeding Education. The health plan has added breastfeeding

information to the prenatal packets sent to all pregnant members. These

materials include a pamphlet describing the benefits of breastfeeding, as well

as an easy-to-understand guide to getting started. Both documents are written

in simple conversational language to ensure comprehension. Subsequently, all

pregnant women receive a call once a trimester and postpartum from a health

information company contracted by UCare to ensure that members have

received the information sent and to identify any potential problems. To

encourage enrollee attendance at childbirth and pregnancy education classes,

including classes on breastfeeding, UCare designed an incentive program that

makes mothers eligible for gift certificates by attending all the classes.

✹ Postpartum Support. After birth, UCare Minnesota continues promoting

breastfeeding within its membership by reimbursing universal home visits for

all mothers after delivery to address any concerns, including breastfeeding.

The health plan has established a full-time maternity case manager position to

handle all high-risk births and problem pregnancies. This case manager can

arrange for referral to a lactation consultant if necessary (a service reimbursed

by UCare Minnesota). The health plan also includes articles about

breastfeeding in the member newsletter, distributes new parent information

packets that encourage breastfeeding, and refers parents to a 24-hour medical

resource telephone line for more breastfeeding information.
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✹ Breast Pumps. In 1997, UCare Minnesota contributed several hundred dollars

to the Ramsey County WIC program to increase their stock of foot pedal

breast pumps. In addition, effective July 1998, UCare expanded its policy on

breast pumps to allow full coverage of pumps less than $250 without prior

authorization (only a physician’s order is required). When medically

necessary, pump rental over $250 can be authorized.

Community Partnerships

✹ Social Support. UCare Minnesota prides itself on its willingness and ability to

collaborate with state and local agencies to provide needed services for

enrollees. An assessment by the Minnesota Institute of Public Health, for the

Minnesota WIC program in the 1990s showed that reasons for not

breastfeeding included lack of medical and familial support, inconvenience,

and embarrassment. The WIC program decided a strategy to promote

community acceptance of, and support for, breastfeeding was an important

component in encouraging more women to breastfeed and developing a

community that would support both the initiation and continuation of this

healthy feeding option.

✹ The United States Department of Agriculture, Food and Consumer Service

also recognized the need for developing community support for breastfeeding.

This recognition lead to development of the WIC National Breastfeeding

Promotion Project via a cooperative agreement with Best Start Social

Marketing. The “Loving Support” campaign was unveiled and welcomed in

1997. While USDA supported development of the campaign, individual states

needed to fund program rollout. The Minnesota WIC Program purchased

pamphlets, posters, and Loving Support Kits for use in WIC clinics, promoted

the campaign to other organizations, and encouraged purchase and use of the

materials within their organizations. WIC also purchased Loving Support

vinyl banners, which were shared with other organizations via the Minnesota

Department of Health library. No funds were available to implement the

media component of the campaign. MDH obtained $10,000 from the MCH

block grant and challenged other organizations to match this amount. UCare

Minnesota stepped forward as the only health plan to contribute to the

initiative by donating $10,000 to the “Loving Support Makes Breastfeeding

Work” campaign in 1998.

These funds, combined with matching funds by WIC and generous public

service contributions, allowed the purchase of 25 billboards placed throughout

Minnesota in 1999; four vinyl bulletins rotated throughout the Minneapolis/St.

Paul area for the year 2000; the purchase of additional banners for display in

public health arenas; purchase of posters for distribution to community

members and providers; and purchase of television and radio spots which

were made available to individual communities if they could obtain placement

for the spots. Materials depict families of various ethnicity and proclaim,

“Give a breastfeeding mom your loving support.” The number 1-877-214-

BABY is included on all materials for mass media. Callers to this line can

obtain phone numbers for sources of breastfeeding support in their

communities.
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✹ Hmong Intervention. In 1997-1998, UCare Minnesota financially supported a

breastfeeding promotion project for Hmong women with the St. Paul/Ramsey

County Department of Public Health. The project interviewed Hmong women

at the Refugee/Preventive Medicine Clinic to identify barriers to breastfeeding

and implemented interventions to encourage Hmong women to breastfeed.

One-on-one interviews with refugees demonstrated that barriers to

breastfeeding, such as lack of information, language barriers, lack of adequate

time with hospital staff, easy access to formula through hospitals and WIC

programs, limited reimbursement for home visits, and social and

environmental barriers, existed within the female Hmong population. Hmong

cultural beliefs also presented a unique challenge.

With these barriers in mind, the clinic staff designed several key interventions

to improve breastfeeding rates among the Hmong women. Strategies such as

one-on-one counseling and education from a respected community member,

inclusion of family members, and brief daily home visits from a public health

nurse allowed staff to build trust with clients through shared dialogue and

provided counseling for mothers and families. In addition, culturally-specific

educational materials were distributed.

Evaluation and Outcomes

In 1999, UCare Minnesota reached out to over 1,700 pregnant enrollees by

providing breastfeeding brochures in all prenatal packets. Through the health plan’s

expanded breast pump payment policy, 336 women received breast pumps free of

charge in 1999. This number is nearly three times the number of pumps distributed

in 1997, prior to the policy change in July 1998.

As the project with Hmong women has continued, it has resulted in a breastfeeding

rate increase from 42% in January 1998 to 60% in December 2000.

Cost

By collaborating with state and local public health agencies to financially support

existing efforts, the health plan is able to monitor expenditures. There are minimal

costs associated with communicating the revised breast pump reimbursement policy

to providers and with mailing educational materials to enrollees.

Lessons Learned

According to health plan staff, many aspects of UCare Minnesota’s Breastfeeding

Promotion Program are highly replicable. Through development of partnerships

and collaborations with state and local agencies such as WIC, the health plan has

been able to effectively build on existing efforts and incorporate specific

breastfeeding promotion strategies into its own benefits structure. Coordination of

health plan efforts with such groups is essential to creating a synergistic improvement

in overall community breastfeeding rates. In addition, UCare Minnesota’s

involvement with the Minnesota Department of Health demonstrates the importance

for all levels of the community to consistently voice support and encouragement

for women to breastfeed. Likewise, member education efforts can easily be replicated

by other health plans, although resources for development and dissemination are

necessary.
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Directions for the Future

UCare Minnesota is committed to continuing its partnerships that support

breastfeeding among members and to continually educating members and providers

about the essential components to successful breastfeeding.

Health Plan Contact Information

Ghita Worcester

Vice President of Public Affairs and Development

UCare Minnesota

P.O. Box 52

Minneapolis, MN 55440-0052

Tel: (612) 676-3634

Fax: (612) 676-6501

E-mail: gworcester@ucare.org
76
77

Health Plans, as Employers,

Supporting Breastfeeding Mothers

Who Return to Work

Introduction

A woman who wants to continue breastfeeding her baby after she returns to

work faces two challenges. First, maintaining an adequate milk supply requires that

she either nurse or pump during working hours because milk supply is directly

related to how often the breasts are stimulated by either a nursing infant or a breast

pump’s suction. If she is not able to either nurse or pump, the woman’s milk supply

will diminish and might cease prematurely.

Second, without nursing or pumping, the woman will likely experience painful

breast engorgement which can cause plugged ducts and potentially lead to mastitis

or a breast infection. Not surprisingly, according to the Washington Business Group

on Health, “for many new mothers, the return to work following maternity leave is

often cited as a significant barrier to continuation of breastfeeding “(81). Employers’

policies and practices that support nursing mothers can make the difference between

continued successful breastfeeding and premature or unwanted weaning.

The health benefits to mother and baby conveyed by breastfeeding translate into

reduced costs to employers due to lower health care costs, decreased abstenteeism,

enhanced productivity, improved employee satisfaction, and a better corporate image.

In a 1995 study of two corporate lactation programs, infants who were breastfed

had 33% fewer illnesses than formula-fed infants and 21% fewer illnesses that led

to a parent’s absence from the workplace. The programs’ overall impact led to a

28% decrease in absenteeism and 36% reduction in sick child health care claims

(82).

It is becoming increasingly common for employers to provide support for nursing

mothers. That support can range from simply providing adequate breaks and a private

room for pumping, to development of a more comprehensive program. As noted in

the HHS Blueprint for Action on Breastfeeding, employers can choose from a broad

range of options to support breastfeeding mothers, including:

✹ Prenatal lactation education specifically tailored for working women;

✹ Corporate policies providing information for all employees on the benefits of

breastfeeding and services available to support breastfeeding women;

✹ Education for personnel about why their breastfeeding co-workers need

support;

✹ Adequate breaks, flexible hours, job sharing, and part-time work;

✹ Private “Mother’s Rooms” for expressing milk in a secure and relaxing

environment;

✹ Access to hospital-grade, autocycling (i.e., electric) breast pumps at the

workplace;

✹ Small refrigerators for safe storage of breast milk;

✹ Subsidization or purchase of individually-owned portable breast pumps for

employees;
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✹ Access to lactation professionals on-site or by phone to give breastfeeding

education, counseling, and support during pregnancy, after delivery, and when

the mother returns to work;

✹ Coordination with on-site or near-site child care programs so infants can be

breastfed during the day; and

✹ Support groups for working mothers with children (81).

While health plans are most often recognized for their role in promoting enrollee

health, health plans are also employers, and as such have a tremendous opportunity

to make a difference in the lives of the women who work for them.

Examples of Health Plan Programs for Employees

As part of the research for this monograph, in the summer of 2000 AAHP invited

its members to submit information on their corporate breastfeeding promotion

programs. From the responses, AAHP selected three examples to illustrate the range

of current approaches.

Aetna Inc.

Corporate Lactation Program

Aetna Inc., headquartered in Hartford, Connecticut, has almost 44,000 employees,

76% of whom are female. Aetna has been providing prenatal education to its

employees since the early 1980s. In the mid-1990s, a multidisciplinary groupincluding representatives from the worklife, disability, employee assistance program,

wellness, and fitness units-joined forces to create a “one-stop shopping” program

that encompasses all the benefits available to employees around the “maternity life

event.” The resulting New Child Program promotes the health of both Aetnaemployed mothers and their babies. In 1996, as part of an ongoing quality

improvement effort, the multidisciplinary group identified a gap in maternity-related

services: helping women return to work following birth. To help fill that gap, Aetna

launched the Corporate Lactation Program.

The Goals of the Corporate Lactation Program are to:

✹ Ease the transition of Aetna mothers returning to work after a maternity leave;

✹ Help sustain breastfeeding for six months or longer;

✹ Help minimize healthcare costs and days lost from work due to infant illness;

✹ Support employee productivity and improve employee satisfaction; and

✹ Provide a supportive workplace culture and help position Aetna as an

“employer of choice.”

Aetna’s Corporate Lactation Program is designed to help new mothers make

informed choices and provides the information and skills they need to breastfeed

their babies.

 This comprehensive program provides services that help new mothers balance

the demands of career and motherhood, and includes the following components:
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Prior to delivery

✹ Two classes taught by a certified breastfeeding consultant to help new mothers

make infant feeding choices and learn the “how to’s” of breastfeeding; and

✹ Access to a breastfeeding consultant to answer questions and prepare new

mothers for a successful breastfeeding experience.

During maternity leave

✹ Ongoing telephone support from the breastfeeding consultant to help ensure

the breastfeeding experience is a positive one; and

✹ Further support from the breastfeeding consultant to help new mothers prepare

for a smooth return to work.

Upon return to work

✹ Access to a state-of-the-art electric breast pump in a clean, private room at the

worksite;

✹ A personal accessory carrying case with bottles and a refrigeration

compartment to store breast milk safely; and

✹ Unlimited consultations with a breastfeeding consultant to help new mothers

meet personal goals.

In addition, Aetna provides other return-to-work measures, including the

availability of flextime and job sharing, as well as encouragement to work with

supervisors on job design.

The program is growing. Each year since the program’s inception, more women

have taken advantage of it. In 1997, 200 women participated. By 1999, that number

grew to 505 women and in 2000, 629 Aetna women took advantage of the program.

The program is available in 34 corporate locations, meaning that 80% of Aetna’s

full-time and part-time female employees have access to the program. (The remaining

20% work largely in sales sites where employees are on the road or work from

home.)

Aetna’s program is successful. According to program staff, a recent survey with

a high 57% response rate revealed the following results:

✹ 59% of those who responded breastfed for 6 months or longer, which is

significantly higher than the national average of 21.1% of working mothers

who maintain breastfeeding for that long;

✹ 95% said the program contributed to the baby’s general state of health;

✹ 89% of the women reported that the program had a positive impact on their

general state of health;

✹ 90% reported that the program helped with a smooth transition back to work;

✹ 87% reported that the program contributed to their ability to balance career

and motherhood; and

✹ 88% said it contributed to their satisfaction with working at Aetna.

Aetna conservatively estimates that the return on investment (ROI) for the

Corporate Lactation Program is 2.18 to 1. This figure is based on a cost model used

in industry research which has demonstrated a reduction in medical costs and time

lost from work due to infant illness in the first year following a baby’s birth.
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Program staff credit the program’s success to three factors: management support,

the comprehensiveness of the service, and the program’s communication strategy.

Aetna routinely includes information about the Corporate Lactation Program in emails that are regularly sent to all employees. Information includes a link to an

internal website so that employees can quickly and easily self-enroll in the program.

The website also includes an educational component about the value of breastfeeding

to mothers and babies-because not all women who explore the site are necessarily

already committed to breastfeeding. In addition, the site includes a section that

addresses concerns that managers may have so that they can have their questions

answered.

Humana, Inc.

HumanaBeginnings NursingMoms

Humana Inc. is headquartered in Louisville, Kentucky and has more than 16,000

employees, approximately 79% of whom are women. The NursingMoms program

was first rolled out in October, 1999 in those markets with the greatest number of

employees. Sixty-five (65) mothers enrolled in 1999. By the end of 2000, the

remaining markets were in operation and an additional 70 new mothers participated.

While currently administered by the human resources department, the

NursingMoms program was initially developed by the corporate education

department. In focusing on women’s health, staff reviewed the data on the benefits

of breastfeeding. One disease in particular captured their attention: otitis media.

Those ear infections are among the top 30 claims for Humana. In addition,

conversations with participants in Humana’s prenatal program for enrollees—

HumanaBeginnings—revealed that one of their major concerns is back-to-work.

As a result, Humana decided to start providing breastfeeding services to their own

employees.

The Goals of NursingMoms Include to:

✹ Provide encouragement and support to mothers wishing to breastfeed their

babies and wanting to continue breastfeeding upon return to work;

✹ Increase the breastfeeding initiation rate among new mother employees;

✹ Provide mothers with the necessary tools to increase the success and duration

rates of breastfeeding;

✹ Meet the Healthy People 2010 goals for breastfeeding duration rates of 50%

of women breastfeeding for six months and 25% for one year.

✹ Demonstrate a lower healthcare cost of breastfed infants in comparison to

infants not in the program;

✹ Show a decreased absence rate among breastfeeding mothers (due to illness of

mother or child); and

✹ Reveal an increase in productivity for mothers in the program.

The NursingMoms program is based on the belief that early education and

preparation are keys to a successful breastfeeding experience. For that reason,

expectant mothers are encouraged to enroll in a breastfeeding class, taught by a

certified lactation consultant/educator. In many Humana markets, these classes are
81

offered on-site and are free to moms wishing to participate in the program. These

classes not only help to prepare an expectant mom for the breastfeeding experience,

but also help her to establish a relationship with a lactation consultant/educator.

This contact can encourage the mother to ask questions after the class has ended or

while she is on maternity leave and still working through any uncertainties of

breastfeeding. By having access to a knowledgeable expert, the mother may be

more likely to continue breastfeeding through problems she may experience, instead

of simply deciding to discontinue.

All moms in the NursingMoms program who attend either an on-site or a

community breastfeeding class are given incentives for their participation. Humana

currently provides each participant with a copy of The Nursing Mother’s Companion

by Kathleen Huggins, RN, MS. In addition, Humana also presents the mothers with

a $25.00 coupon toward the purchase of a breastfeeding kit and/or insulated carrying

bag from Medela®. These kits hook up to the hospital-quality Medela® double breast

pumps provided in the many lactation rooms provided at the workplace. In addition,

the private rooms contain educational material on breastfeeding, as well as

information on women’s and children’s health, wellness, and safety issues.

The NursingMoms program monitors participant satisfaction as well as

measurable outcomes and tracks all participants in a specially designed database.

When a mother completes the program by discontinuing breastfeeding, she is asked

to complete an exit survey. Upon turning it in, she is given the book, What to Expect

in the Toddler Years, as a “thank you” for her participation in the program.

Humana is evaluating NursingMoms primarily through participant surveys to

demonstrate participation, satisfaction and self-reported health information. Claims

data will be necessary to validate health outcomes.

Staff list the following components as essential for any other employer that wishes

to replicate the program:

✹ Commitment and desire of management to help and encourage mothers

returning to work to continue to breastfeed their baby;

✹ Significant female population of childbearing age;

✹ Schedule flexibility so that women can express their milk two to three times

per day

✹ Building services available for ongoing room maintenance; and

✹ Program coordinator to oversee the program, facilitate data collection and

promote and gather feedback.

In addition, staff note that the following are beneficial but not essential:

✹ Employee newsletter (or intranet site) to promote the program; and

✹ In large companies with multiple facilities a database is extremely helpful for

measurement and tracking
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Physicians Health Plan of Northern Indiana, Inc.

Lactation Program

Physicians Health Plan of Northern Indiana is a small company with 104

employees, 80% of whom are female. The health plan is located in Fort Wayne,

Indiana. The Lactation Program began in 1995, spurred by the company’s generally

family-friendly orientation. The health education department was already working

to promote breastfeeding to its employer groups so it was a natural step to offer a

program to the health plan’s own employees. 1995 was also a good time to start;

design for the “mother’s room” could be built right into the plans for the company’s

brand-new building.

The goal of the program is to provide encouragement to mothers to continue

breastfeeding when returning to work by having a room that creates a comfortable

and functional environment in which to accomplish this. The “mother’s room” has

a lock for privacy, a comfortable recliner, and an electric breast pump. Designed for

use by one woman at a time, the room has a sign-in sheet so that nursing mothers

can coordinate their schedules. Managers work with employees to schedule pumping

sessions during the day. Attachments for the breast pump and coolers for storing

expressed milk are available to employees for purchase at cost.

While no formal evaluation of the program has been conducted, staff of Physicians

Health Plan of Northern Indiana report that women who use the room are very

satisfied and that some even use it for an entire year, which suggests that its existence

promotes continued breastfeeding.
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Appendix A:

AAHP’s Women’s Health Subcommittee

Joanne Armstrong, MD

Aetna Health Plans

Sandra Aronberg, MD, MPH

Blue Shield of California

Mary Baker, RN, MSN, AOCN

HIP Health Plan

Michele DiPalo, ABD

Blue Cross Blue Shield of Massachusetts

Deirdre Finnegan

Oxford Health Plans

Patricia Greenfield, RN DNSc

Kaiser Permanente, Mid-Atlantic

Mary Jo Kingston, MA, LP

PreferredOne

Richard A. Kopher, MD

HealthPartners, Inc.

Mitzi Krockover, MD

Humana Inc.

Jay Kulkin, MD, MBA

Blue Cross Blue Shield of Georgia

Susan Ortiz, RN, MSN

Kaiser Permanente of Southern California

Robin S. Richman, MD (chair)

Tufts Health Plan

Cheri Rolnick, PhD, MPH

HealthPartners Research Foundation

Linda Ruhl, PA-C

Highmark Blue Cross Blue Shield

Derek van Amerongen, MD, MS (Vice-Chair)

ChoiceCare/Humana

Juanita L. Watts MD

Kaiser Permanente,

Southern California Permanente Medical Group
89

Appendix B:

Breastfeeding Monograph

Review Committee

Delores F. Baker, MD

The Wellness Plan

Julie Gazmararian, MPH, PhD

USQA Center for Health Care Research

Richard Kopher, MD

HealthPartners,

Tracy Lieu, MD, MPH

Harvard Pilgrim Health Care

Leith Mullaly, RNC, MSN, IBCLC

Association of Women’s Health, Obstetric and Neonatal Nurses

Denise Sofka, MPH, RD

Maternal Child Health Bureau

Health Resources and Services Administration (HRSA)

Suzanne Haynes, PhD

Office on Women’s Health

Department of Health and Human Services