title: The New Hampshire Ten Steps to Successful Breastfeeding Collaborative: A Statewide QI Initiative.
abstract: OBJECTIVE
  Despite national recognition for their breastfeeding-friendly practices, many New Hampshire hospitals are still not achieving the Ten Steps to Successful Breastfeeding. To increase achievement of the Ten Steps in New Hampshire's birthing hospitals, facilitate Baby-Friendly Hospital Initiative (BFHI) designation for interested hospitals, and improve rates of in-hospital any and exclusive breastfeeding.
  
  
  METHODS
  After a 2010 needs assessment, we conducted 2 statewide workshops targeting 6 of the Ten Steps found to be most deficient among New Hampshire birthing hospitals. Eighteen of 20 hospitals attended at least 1 workshop, and 6 participated in an intensive collaborative. In 2013, we analyzed interval Ten Step achievement and in-hospital breastfeeding trends.
  
  
  RESULTS
  Staff education showed the greatest improvement, increasing step 2 achievement from 1 to 6 hospitals (P=.05). Although the number of hospitals implementing step 6 (breast milk only) and step 9 (no artificial nipples) increased, differences were not statistically significant. Intensive collaborative hospitals achieved an average of 1.5 new steps, whereas non-Baby Friendly hospitals lost 0.7 steps (P=.05). In-hospital breastfeeding rates increased in intensive collaborative hospitals and were significantly higher than those in non-Baby Friendly hospitals by the end of the study (any breastfeeding, 89% vs 73%, P=.03; exclusive breastfeeding, 84% vs 61%, P<.001).
  
  
  CONCLUSIONS
  A statewide improvement collaborative facilitated increases in Ten Step achievement and in-hospital breastfeeding for hospitals participating in an intensive collaborative. Active work in Ten Step implementation, including staff education, appears to be more effective in increasing in-hospital breastfeeding than does BFHI designation alone.
authors.affiliation: Department of Pediatrics, The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Department of Pediatrics, Children's Hospital at Dartmouth, and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; and bonny.l.whalen@hitchcock.org.
authors.forename: Bonny L
authors.initials: BL
authors.lastname: Whalen
authors.affiliation: The New Hampshire Breastfeeding Taskforce, Concord, New Hampshire.
authors.forename: Joyce
authors.initials: J
authors.lastname: Kelly
authors.affiliation: Department of Pediatrics, The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Department of Pediatrics, Children's Hospital at Dartmouth, and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; and.
authors.forename: Alison Volpe
authors.initials: AV
authors.lastname: Holmes
mesh_terms: D001942:Breast Feeding / Q000706:statistics & numerical data*; D003299:Cooperative Behavior; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006293:Health Promotion / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D009513:New Hampshire; D015397:Program Evaluation / Q000706:statistics & numerical data*; D058996:Quality Improvement / Q000706:statistics & numerical data*
keywords: BFHI; Baby-Friendly Hospital Initiative; Ten Steps to Successful Breastfeeding; baby friendly; baby-friendly; breastfeeding; exclusive breastfeeding; infant feeding