Case Studies

Better Breastfeeding for Healthier Moms and Babies

The Texas Ten Step Star Achiever Breastfeeding Learning Collaborative is an innovative statewide initiative that took place between 2012 and 2017. NICHQ partnered with the Texas Department of State Health Services and the Texas Women, Infants and Children (WIC) program to support 74 hospital-based teams in using quality improvement methodology to create and maintain an environment that promotes breastfeeding, with the ultimate aim of increasing overall and exclusive breastfeeding rates.  

Both mothers and babies experience life-long benefits from breastfeeding. Multiple cancer and disease risks are lowered for breastfeeding mothers, and breastfed babies show a reduction of a range of health concerns, from leukemia to asthma to infection. Yet breastfeeding remains a significant public health issue, with national averages falling below the Healthy People 2020 objectives. As a result, thousands of mothers and babies will miss out on the health benefits of breastfeeding.

Our Approach

Over the course of three sequential cohorts, NICHQ instructed 74 hospital-based teams on quality improvement (QI) methodology, providing specific and actionable strategies to create lasting organizational change and track progress in breastfeeding outcomes. All strategies supported the recommendations from the Texas 10 Step Program, developed to improve maternity care practices in Texas birthing facilities. Through monthly coaching calls, in-person learning sessions, site visits and an online collaborative community, teams received guidance on how to use QI methodology to introduce and implement evidence-based breastfeeding practices at their facilities. The QI methodology focused on collecting data for learning, using small tests of change for improvement and a collaborative learning environment where teams could steal shamelessly and share seemlessly. This approach provided rigor, structure and peer learning as teams sought to increase breastfeeding rates in their hospitals.

The Results

NICHQ has impacted the lives of 152,000 mothers and infants who received maternity care at the 74 hospitals during the project period. Over the course of the initiative,

  • Texas 10 Step facilities increased by 47 percent
  • Baby-Friendly facilities increased by over 200 percent
  • Breastfeeding outcomes were significantly impacted for Hispanic and African American infants
  • Community partnerships between WIC and hospital initiatives were solidified, benefiting the many hospitals nationwide serving WIC-eligible mothers and infants 

Signals of future change:

While changes to exclusive breastfeeding rates often take years to capture, multiple hospitals have already shown significant improvement, indicating future success across the collaborative. The results from three separate hospitals, which we’ve been asked to de-identify, are shown below:

  • Hospital A saw exclusive breastfeeding rates increase from 19 to 43 percent
  • Hospital B showed an increase of 37 to 46 percent in its exclusive breastfeeding rate
  • Hospital C showed an increase of 27 to 40 percent in its exclusive breastfeeding rate
Breastfeeding mother and baby


The culture of breastfeeding in Texas has radically changed over the course of the five-year improvement initiative. There are now 131 hospitals with the Texas 10 Step designation and 22 organizations designated as Baby-Friendly or on the Baby-Friendly pathway. With Texas representing 10 percent of births in the U.S. each year, this improvement has national implications. By putting in place a quality improvement framework focused on collaborative learning and vast stakeholder engagement, NICHQ has paved the way for Texas to continue to improve maternity care practices and breastfeeding rates across the state. And due to Texas’ wide geographic expanse and diverse population, their achievements provide a comprehensive model for breastfeeding improvement efforts in other states and regions.

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