Implementing the WHO/UNICEF Baby Friendly Initiative in the community: a 'hearts and minds' approach

Breastfeeding experience of postnatal mothers separated from preterm infants after discharge: a phenomenology qualitative approach

BACKGROUND

Breastfeeding practices are influenced by the maternal-infant bond relationship. Mothers of preterm infants in the puerperium face many challenges and support is needed to maintain breastfeeding after hospital discharge. This study explored the breastfeeding experiences among mothers of preterm infants and challenges that influenced their breastfeeding practices.

METHODS

A qualitative phenomenological approach was used involving the mothers of preterm infants during the puerperium in Shanghai who fulfilled the inclusion criteria and consented to participate in the study. The mothers were recruited using purposive sampling. Eighteen participants were interviewed using semi-structured in-depth interviews. All interviews were recorded in digital audio, transcribed verbatim, and analyzed using thematic analysis.

FINDINGS

The breastfeeding experience among mothers of preterm infants included four themes: breastfeeding motivation, breastfeeding challenges, breastfeeding support and education, and response to parental stress. Breastfeeding challenges included perceived insufficient milk, bottle preference, and maternal-infant separation. Two sub-themes of breastfeeding support included breastfeeding knowledge and approach.

CONCLUSION

To overcome breastfeeding challenges and improve the breastfeeding rate of preterm infants after discharge, medical professionals must develop individualized breastfeeding plans based on a comprehensive assessment of the needs of mothers who delivered a preterm infant.

Improving breastfeeding support through the implementation of the Baby-Friendly Hospital and Community Initiatives: a scoping review

BACKGROUND

Improved breastfeeding practices have the potential to save the lives of over 823,000 children under 5 years old globally every year. The Baby-Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organization and the United Nations Children's Fund, which promotes best practice to support breastfeeding in maternity services. The Baby-Friendly Community Initiative (BFCI) grew out of step 10, with a focus on community-based implementation. The aim of this scoping review is to map and examine the evidence relating to the implementation of BFHI and BFCI globally.

METHODS

This scoping review was conducted according to the Joanna Briggs Institute methodology for scoping reviews. Inclusion criteria followed the Population, Concepts, Contexts approach. All articles were screened by two reviewers, using Covidence software. Data were charted according to: country, study design, setting, study population, BFHI steps, study aim and objectives, description of intervention, summary of results, barriers and enablers to implementation, evidence gaps, and recommendations. Qualitative and quantitative descriptive analyses were undertaken.

RESULTS

A total of 278 articles were included in the review. Patterns identified were: i) national policy and health systems: effective and visible national leadership is needed, demonstrated with legislation, funding and policy; ii) hospital policy is crucial, especially in becoming breastfeeding friendly and neonatal care settings iii) implementation of specific steps; iv) the BFCI is implemented in only a few countries and government resources are needed to scale it; v) health worker breastfeeding knowledge and training needs strengthening to ensure long term changes in practice; vi) educational programmes for pregnant and postpartum women are essential for sustained exclusive breastfeeding. Evidence gaps include study design issues and need to improve the quality of breastfeeding data and to perform prevalence and longitudinal studies.

CONCLUSION

At a national level, political support for BFHI implementation supports expansion of Baby-Friendly Hospitals. Ongoing quality assurance is essential, as is systematic (re)assessment of BFHI designated hospitals. Baby Friendly Hospitals should provide breastfeeding support that favours long-term healthcare relationships across the perinatal period. These results can help to support and further enable the effective implementation of BFHI and BFCI globally.

Involvement of Civil Society Organization in Facilitating the Implementation of Ten Steps for Successful Breastfeeding: Analysis of Health Care Workers' Perspectives?

Despite the present of national policy support, the prevalence of early breastfeeding initiation in Indonesia are still low. Research has shown that health care workers are the most reliable source for breastfeeding advice, but sadly they were often lacking in capacity. The aim of the study to assess the involvement of civil society organization (CSO) and its associated factors in facilitating the implementation of Ten Steps for Successful Breastfeeding (TSSB) based on health care workers' perspectives in Malang and Sidoarjo districts, East Java Province, Indonesia. We used qualitative approach to in-depth interview 117 participants and conducted 14 FGDs in Sidoarjo and Malang East Java. the PARiHS framework was used to identify the role of CSO in facilitating the BFHI implementation from the health workers perspective to offer insight on the facilitation process and development of future recommendations. The study found that the health care workers' have good knowledge on the benefits of breastfeeding with significant portion of the knowledge that they hold are coming from trainings provided by the CSO. There was cultural context barriers within the community, where grandmothers are considered as an important influence factor esspecially for working mothers. The implementation of training by the CSO was considered appropriate due to its ability to address some pressing structural obstacles and provide not only training to improve evidence but also help in addressing other contextual barriers. The CSO has offered opportunities not only for dissemination of evidence-based intervention but also to close gaps on resources provision to attend courses.

UNICEF UK Baby Friendly Initiative: Providing, receiving and leading infant feeding care in a hospital maternity setting-A critical ethnography

Although breastfeeding is known to improve health, economic and environmental outcomes, breastfeeding initiation and continuation rates are low in the United Kingdom. The global WHO/UNICEF Baby Friendly Hospital Initiative (BFHI) aims to reverse declining rates of breastfeeding by shifting the culture of infant feeding care provision throughout hospital maternity settings. In the United Kingdom, the global BFHI has been adapted by UNICEF UK reflecting a paradigm shift towards the experiences of women and families using maternity services. This research used a critical ethnographic approach to explore the influence of the national UNICEF UK Baby Friendly Initiative (BFI) standards on the culture of one typical maternity service in England, over a period of 8 weeks, across four phases of data collection between 2011 and 2017. Twenty‐one staff and 26 service users were recruited and engaged in moderate‐level participant observation and/or guided interviews and conversations. Basic, organising and a final global theme emerged through thematic network analysis, describing the influence of the BFI on providing, receiving and leading infant feeding care in a hospital maternity setting. Using Antonovsky's sense of coherence construct, the findings discussed in this paper highlight how the BFI offers ‘informational’ (comprehensible), ‘practical’ (manageable) and ‘emotional’ (meaningful) support for both staff and service users, strengthened by effective, local leadership and a team approach. This is juxtaposed against the tensions and demands of the busy hospital maternity setting. It is recommended that ongoing infant feeding policy, practice and leadership balance relational and rational approaches for positive infant feeding care and experiences to flourish.

Factors associated with breastfeeding support from health care professionals by implementing a Clinical Practice Guideline

BACKGROUND

The prevalence and duration of breastfeeding are at low levels and may be improved by the support of health care professionals. Our objective was to determine the effect of implementing a breastfeeding clinical practice guideline on factors associated with breastfeeding support by health care professionals, adopting a Theory of Planned Behavior approach.

METHODS

We conducted an observational, cross-sectional study during 2016 in a health area with implemented clinical practice guideline on breastfeeding, comparing the results with data from a previous cross-sectional study (2011) in the same area, in a standard-care area, and in a Baby-Friendly Hospital Initiative (BFHI)-accredited area. A validated questionnaire (four scales: attitudes, beliefs, subjective norms, and behavioral intention) was completed by professionals in each area. Descriptive analysis was followed by comparisons among the different settings using the chi-square test.

RESULTS

In the area with the implemented clinical practice guideline, the professionals scored significantly higher in subjective norms and beliefs than had been recorded in 2011 (preimplementation), and their scores for all four scales were significantly higher than in the standard-care area. Professionals obtained significantly higher scores for subjective norms in the BFHI-accredited area than in the other settings.

CONCLUSIONS

Clinical practice guideline implementation improved the responses of professionals on breastfeeding support in subjective norms and beliefs scales. There is a need for activities to assist breastfeeding in a practical manner and for more effective measures to ensure compliance with the International Code of Marketing of Breast-milk Substitutes.

The uptake and implementation of the Baby Friendly Health Initiative in Australia

PROBLEM

Despite evidence that implementation of the Initiative has been effective in increasing breastfeeding rates and duration of breastfeeding worldwide; the uptake is low with only 70 Baby Friendly accredited maternity facilities across Australia (approximately 23% of facilities).

BACKGROUND

The Ten Steps to Successful Breastfeeding and International Code of Marketing of Breastmilk Substitutes shaped the foundation for the Initiative to implement practices that protect, promote and support breastfeeding. There is evidence that implementation of the Initiative is impacted by individual and organisational culture, organisational support, and education. Organisational change is also identified as playing an important role in the successful implementation of the Initiative. Despite policy and guideline support for the Initiative at national and state levels in Australia the uptake of the Initiative is low.

AIM

The aim of this research was to explore health practitioners' perspectives about the uptake and implementation of the Initiative in Australia.

METHODS

Semi-structured, face-to-face, telephone and Skype interviews were conducted with 12 health practitioners. Thematic analysis was used to analyse data.

RESULTS

Participants identified that the uptake and implementation of the Initiative in Australia is complex. This complexity was related to six themes: (1) policy and guideline support for the Initiative, (2) leadership support to implement the Initiative, (3) improving breastfeeding and Initiative-related knowledge, (4) improving communication between stakeholders regarding the Initiative, (5) accreditation and reaccreditation processes, and (6) implementation complexity.

CONCLUSION

Using organisational change theories as a guide to implementation of the Initiative may be useful for facilities intending to become accredited.

Therapeutic effect of a cleft lip teat on infants with respiratory and feeding disorders: Two case reports

RATIONALE

Existing research into the effects of teat application has mainly focused on its negative and positive influence on the development of the oral cavity. Our work demonstrates that apart from changing the setting of the articulatory organs, the teat can also affect the quality of breathing, eating and sleeping.

PATIENTS CONCERNS

We described the cases of 2 children: a 19-month-old girl and a 2.5-month-old boy, who had breathing disorders due to withdrawal of the tongue and impaired food intake.

INTERVENTION

The babies were bottled fed with a special teat for cleft lip patients to observe the influence of the teat on the setting of the articulatory organs and breathing.

DIAGNOSIS

We suspected that the specific construction of the teat-the wide outer part and the short internal part-would affect children's reflexes and articulatory organs so as to force the frontal position of the tongue, which was meant to facilitate breathing and eating.

OUTCOMES

It was found that feeding with the cleft lip teat stimulates the gyro-linguistic muscle, which results in the proper position of the tongue and consequently better breathing and improved quality of sleep.

LESSONS

A specialist bottle teat designed for babies with cleft lips can constitute an effective tool in the therapy of nonspecific respiratory disorders resulting from improper position of the tongue and other articulatory organs.

Global implications of the new WHO and UNICEF implementation guidance on the revised Baby-Friendly Hospital Initiative

Although breastfeeding confers both short- and long-term benefits for children and their mothers, breastfeeding practice remains suboptimal, globally. In addition to barriers including misperceptions and inappropriate marketing of breast milk substitutes, inadequate support for breastfeeding remains a challenge in many settings. To improve access to appropriate health system support, the World Health Organization (WHO) has reviewed the Baby-Friendly Hospital Initiative (BFHI), which ensures provision of optimal clinical care and support to mothers and their infants. This review has resulted in revision of the Ten Steps to Successful Breastfeeding, which form the core standards of (BFHI). These now consist of critical management procedures to support breastfeeding (Steps 1 and 2) and key clinical practices to support breastfeeding (Steps 3-10). In Step 1, there is now specific emphasis on compliance with the WHO Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions as well as on internal monitoring. There are also significant position shifts like the recommendation to "Counsel mothers on the use and risks of feeding bottles, teats, and pacifiers," which is a departure from the earlier position of avoiding reference to these technologies. These revisions require countries and states to revise activities and tools for their local situation but without compromising the standards.

Implementing a WIC-Based Intervention to Promote Exclusive Breastfeeding: Challenges, Facilitators, and Adaptive Strategies

OBJECTIVE

Understand factors that contributed to the implementation of a successful multicomponent intervention to promote exclusive breastfeeding (EBF) within Special Supplemental Nutrition Program for Woman, Infants, and Children (WIC) clinics.

DESIGN

Qualitative study of staff implementers' experiences using implementation status reports, facilitated group discussion immediately after implementation, and WIC administrative data.

SETTING

WIC staff from 12 clinics participated in an EBF Learning Community composed of 8 intervention trainings and ongoing support from trainers and peers.

PARTICIPANTS

A total of 47 WIC staff including 11 directors, 20 other administrators, 8 nutritionists, and 6 peer counselors.

INTERVENTION

A WIC-integrated EBF promotion initiative, supported through a Learning Community, composed of prenatal screening, tailored trimester-specific counseling, and timely postpartum follow-up.

PHENOMENON OF INTEREST

Challenges and facilitators to implementation within clinics.

ANALYSIS

Iterative qualitative analysis using directed, emergent, and thematic coding.

RESULTS

Implementation experiences were characterized by (1) perceived benefits of implementation, including improved EBF knowledge and counseling confidence among staff; and (2) managing implementation, including responding to challenges posed by clinic settings (resources, routine practices, values, and perceptions of mothers) through strategies such as adapting clinic practices and intervention components.

CONCLUSIONS AND IMPLICATIONS

Implementation was shaped by clinic setting and adaptive strategies. Future WIC interventions may benefit from formal consideration of intervention fit with local clinic setting and allowable adaptations.

Understanding process and context in breastfeeding support interventions: The potential of qualitative research

Considerable effort has been made in recent years to gain a better understanding of the effectiveness of different interventions for supporting breastfeeding. However, research has tended to focus primarily on measuring outcomes and has paid comparatively little attention to the relational, organizational, and wider contextual processes that may impact delivery of an intervention. Supporting a woman with breastfeeding is an interpersonal encounter that may play out differently in different contexts, despite the apparently consistent aims and structure of an intervention. We consider the limitations of randomized controlled trials for building understanding of the ways in which different components of an intervention may impact breastfeeding women and how the messages conveyed through interactions with breastfeeding supporters might be received. We argue that qualitative methods are ideally suited to understanding psychosocial processes within breastfeeding interventions and have been underused. After briefly reviewing qualitative research to date into experiences of receiving and delivering breastfeeding support, we discuss the potential of theoretically informed qualitative methodologies to provide fuller understanding of intervention processes by focusing on three examples: phenomenology, ethnography, and discourse analysis. The paper concludes by noting some of the epistemological differences between the broadly positivist approach of trials and qualitative methodologies, and we suggest there is a need for further dialog as to how researchers might bridge these differences in order to develop a fuller and more holistic understanding of how best to support breastfeeding women.

What Do Women Really Want? Lessons for Breastfeeding Promotion and Education

BACKGROUND

Promoting breastfeeding is a strategic priority, but breastfeeding rates remain low in the United Kingdom. Women value breastfeeding promotion and education, but a different strategy may be needed to continue to raise breastfeeding rates. New mothers, as the experts, are best placed to inform these changes. The current study explored new mothers' attitudes toward breastfeeding education and promotion, evaluating experiences and examining ideas for change.

MATERIALS AND METHODS

One thousand one hundred thirty mothers with a baby aged 0-2 years old who had planned to breastfeed at birth completed a questionnaire consisting of both closed and open-ended questions exploring their attitudes to breastfeeding promotion and support.

RESULTS

Overall, the findings showed that mothers valued breastfeeding information, but believed that changes needed to be made to current messages. Key themes included a move away from the perception that breastfeeding is best (rather than normal), emphasis on wider values other than the health benefits of breastfeeding, and a message that every feed, rather than just 6 months exclusive breastfeeding, matters. Mothers also highlighted the need for promotion and education to target family members and wider society rather than simply mothers themselves, all of whom influenced both directly or indirectly maternal decision and ability to breastfeed. Mothers suggested ideas for promotional campaigns or how specific groups or methods could be used to increase support, including education for children, TV adverts, and using established online sources of breastfeeding information.

CONCLUSIONS

The findings are important both for those supporting new mothers to breastfeed and those involved in breastfeeding policy and promotional messages.

Feasibility and effectiveness of the baby friendly community initiative in rural Kenya: study protocol for a randomized controlled trial

BACKGROUND

Interventions promoting optimal infant and young child nutrition could prevent a fifth of under-5 deaths in countries with high mortality. Poor infant and young child feeding practices are widely documented in Kenya, with potential detrimental effects on child growth, health and survival. Effective strategies to improve these practices are needed. This study aims to pilot implementation of the Baby Friendly Community Initiative (BFCI), a global initiative aimed at promoting optimal infant and young child feeding practices, to determine its feasibility and effectiveness with regards to infant feeding practices, nutrition and health outcomes in a rural setting in Kenya.

METHODS

The study, employing a cluster-randomized trial design, will be conducted in rural Kenya. A total of 12 clusters, constituting community units within the government's Community Health Strategy, will be randomized, with half allocated to the intervention and the other half to the control arm. A total of 812 pregnant women and their respective children will be recruited into the study. The mother-child pairs will be followed up until the child is 6 months old. Recruitment will last approximately 1 year from January 2015, and the study will run for 3 years, from 2014 to 2016. The intervention will involve regular counseling and support of mothers by trained community health workers and health professionals on maternal, infant and young child nutrition. Regular assessment of knowledge, attitudes and practices on maternal, infant and young child nutrition will be done, coupled with assessment of nutritional status of the mother-child pairs and morbidity for the children. Statistical methods will include analysis of covariance, multinomial logistic regression and multilevel modeling. The study is funded by the NIH and USAID through the Program for Enhanced Research (PEER) Health.

DISCUSSION

Findings from the study outlined in this protocol will inform potential feasibility and effectiveness of a community-based intervention aimed at promoting optimal breastfeeding and other infant feeding practices. The intervention, if proved feasible and effective, will inform policy and practice in Kenya and similar settings, particularly regarding implementation of the baby friendly community initiative.

TRIAL REGISTRATION

ISRCTN03467700 ; Date of Registration: 24 September 2014.

The bumpy road to implementing the Baby-Friendly Hospital Initiative in Austria: a qualitative study

BACKGROUND

The Baby-Friendly Hospital Initiative (BFHI) aims to promote and support breastfeeding. Globally, around 20,000 facilities have been designated Baby-Friendly. In Austria, however, only 16% of the maternity units have received BFHI-certification. Internationally, few studies have investigated facilitating or hindering factors for BFHI implementation. The need to extend BFHI-certification rates has been investigated previously, but little is known about why maternity units decide to become BFHI-certified, how BFHI is installed at the unit level, and which factors facilitate or impede the operation of the BFHI in Austria and how barriers are overcome.

METHODS

Using a qualitative approach, (health) professionals' perceptions of the selection, installation, as well as facilitators of and barriers to the BFHI were investigated. 36 semi-structured interviews with persons responsible for BFHI implementation (midwives, nurses, physicians, quality manager) were conducted in three Austrian maternity units. Data were analyzed using thematic analysis.

RESULTS

Interviewees mentioned several motives for selecting the BFHI, including BFHI as a marketing tool, improvement of existing services, as well as collaboration between different professional groups. In each hospital, "change agents" were identified, who promoted the BFHI, teamed up with the managers of other professional groups and finally, with the manager of the unit. Installation of BFHI involved the adoption of project management, development and dissemination of new standards, and training of all staff. Although multiple activities were planned to prepare for actually putting the BFHI into practice, participants mentioned not only facilitating, but also several hindering factors. Interpretations of what facilitated or impeded the operation of BFHI differed among and between professional groups.

CONCLUSION

Successful implementation of the BFHI in Austria depends on a complex interplay of multiple factors including a consensual "bottom-up" selection process, followed by a multifaceted installation stage. Even these activities may be perceived as a hindrance for non-BFHI-certified hospitals. Findings also suggest that despite active preparation, several barriers have to be overcome when BFHI is actually incorporated into routine practices. BFHI seems to pose a great challenge to health professionals' work routines and, thus, clear structural changes of such routines as well as ongoing monitoring and support activities are required.

Factors influencing the intention of perinatal nurses to adopt the baby-friendly hospital initiative in southeastern quebec, Canada: implications for practice

Nurses play a major role in promoting the baby-friendly hospital initiative (BFHI), yet the adoption of this initiative by nurses remains a challenge in many countries, despite evidences of its positive impacts on breastfeeding outcomes. The aim of this study was to identify the factors influencing perinatal nurses to adopt the BFHI in their practice. Methods. A sample of 159 perinatal nurses from six hospital-based maternity centers completed a survey based on the theory of planned behavior. Hierarchical multiple linear regression analyses were performed to assess the relationship between key independent variables and nurses' intention to adopt the BFHI in their practice. A discriminant analysis of nurses' beliefs helped identify the targets of actions to foster the adoption the BFHI among nurses. Results. The participants are mainly influenced by factors pertaining to their perceived capacity to overcome the strict criteria of the BFHI, the mothers' approval of a nursing practice based on the BFHI, and the antenatal preparation of the mothers. Conclusions. This study provides theory-based evidence for the development of effective interventions aimed at promoting the adoption of the BFHI in nurses' practice.

A meta-ethnographic study of health care staff perceptions of the WHO/UNICEF Baby Friendly Health Initiative

BACKGROUND

Implementation of the Baby Friendly Health Initiative (BFHI) is associated with increases in breastfeeding initiation and duration of exclusive breastfeeding and 'any' breastfeeding. However, implementation of the BFHI is challenging.

AIM

To identify and synthesise health care staff perceptions of the WHO/UNICEF BFHI and identify facilitators and barriers for implementation.

METHOD

Seven qualitative studies, published between 2003 and 2013 were analysed using meta-ethnographic synthesis.

FINDINGS

Three overarching themes were identified. First the BFHI was viewed variously as a 'desirable innovation or an unfriendly imposition'. Participants were passionate about supporting breastfeeding and improving consistency in the information provided. This view was juxtaposed against the belief that BFHI represents an imposition on women's choices, and is a costly exercise for little gain in breastfeeding rates. The second theme highlighted cultural and organisational constraints and obstacles to BFHI implementation including resource issues, entrenched staff practices and staff rationalisation of non-compliance. Theme three captured a level of optimism and enthusiasm amongst participants who could identify a dedicated and credible leader to lead the BFHI change process. Collaborative engagement with all key stakeholders was crucial.

CONCLUSIONS

Health care staff hold variant beliefs and attitudes towards BFHI, which can help or hinder the implementation process. The introduction of the BFHI at a local level requires detailed planning, extensive collaboration, and an enthusiastic and committed leader to drive the change process. This synthesis has highlighted the importance of thinking more creatively about the translation of this global policy into effective change at the local level.

Applying organisation theory to understand barriers and facilitators to the implementation of baby-friendly: A multisite qualitative study

OBJECTIVES

(a) to apply an organisation-level, pre-implementation theory to identify and describe factors that may impact hospitals' readiness to achieve the Ten Steps and (b) to explore whether/how these factors vary across hospitals.

DESIGN

a multisite, descriptive, qualitative study of eight hospitals that used semi-structured interviews of health-care professionals. Template analyses identified factors that related to organisation-level theory. Cross-site comparative analyses explored how factors varied across hospitals.

SETTING

thirty-four health-care professionals from eight North Carolina hospitals serving low-wealth populations. The hospitals are participating in a quality improvement project to support the implementation of the Ten Steps. This study occurred during the pre-implementation phase.

FINDINGS

several factors emerged relating to collective efficacy (i.e., the shared belief that the group, as a whole, is able to implement the Steps) and collective commitment (i.e., the shared belief that the group, as a whole, is committed to implementing the Steps) to implement the Ten Steps. Factors relating to both constructs included 'staff age/experience,' 'perceptions of forcing versus supporting mothers,' 'perceptions of mothers' culture,' and 'reliance on lactation consultants.' Factors relating to commitment included 'night versus day shift,' 'management support,' 'change champions,' 'observing mothers utilize breastfeeding support.' Factors relating to efficacy included 'staffing,' 'trainings,' and 'visitors in room.' Commitment-factors were more salient than efficacy-factors among the three large hospitals. Efficacy-factors were more salient than commitment-factors among the smaller hospitals.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

interventions focused on implementing the Ten Step may benefit from improving collective efficacy and collective commitment. Potential approaches could include skills-based, hands-on training highlighting benefits for mothers, staff, and the hospital, and addressing context-specific misconceptions about the Steps.

Breastfeeding promotion plan in Madrid, Spain

BACKGROUND

Promotion and protection of breastfeeding is a public health objective. In April 2009, health authorities in the Madrid region in central Spain signed a collaboration agreement with The United Nations Children's Fund and created a breastfeeding committee.

OBJECTIVE

To report the creation and implementation of a plan to promote and improve the quality of breastfeeding care in public hospitals in the region of Madrid, according to the Baby-Friendly Hospital Initiative (BFHI) standards.

METHODS

The action plan included institutional commitment; creation of a breastfeeding committee in each hospital; outcome analyses, staff training, creation of educational materials; and dissemination of activities. The plan was adopted by the 19 non-BFHI-designated public maternity units in the Madrid region. Each hospital completed a modified version of the World Health Organization self-assessment questionnaire in 2009 (pre-intervention) and again in 2011.

RESULTS

Thirteen maternity units (68.4%) established a breastfeeding committee, and 32 months after implementation of the plan, the other 6 hospitals have created one. Nine training courses have been carried out to train professional experts on breastfeeding as trainers. The 271 trainers provided 18-hour breastfeeding courses for 1423 professionals. In 2009, there was only 1 BFHI-accredited hospital. Currently, 52.6% of the other 19 hospitals have some level of accreditation, and 2 are fully accredited.

CONCLUSIONS

An intervention to improve the quality of breastfeeding care based on an organized regional approach to the BFHI was useful for BFHI implementation.

Ten steps or climbing a mountain: a study of Australian health professionals' perceptions of implementing the baby friendly health initiative to protect, promote and support breastfeeding

BACKGROUND

The Baby Friendly Hospital (Health) Initiative (BFHI) is a global initiative aimed at protecting, promoting and supporting breastfeeding and is based on the ten steps to successful breastfeeding. Worldwide, over 20,000 health facilities have attained BFHI accreditation but only 77 Australian hospitals (approximately 23%) have received accreditation. Few studies have investigated the factors that facilitate or hinder implementation of BFHI but it is acknowledged this is a major undertaking requiring strategic planning and change management throughout an institution. This paper examines the perceptions of BFHI held by midwives and nurses working in one Area Health Service in NSW, Australia.

METHODS

The study used an interpretive, qualitative approach. A total of 132 health professionals, working across four maternity units, two neonatal intensive care units and related community services, participated in 10 focus groups. Data were analysed using thematic analysis.

RESULTS

Three main themes were identified: 'Belief and Commitment'; 'Interpreting BFHI' and 'Climbing a Mountain'. Participants considered the BFHI implementation a high priority; an essential set of practices that would have positive benefits for babies and mothers both locally and globally as well as for health professionals. It was considered achievable but would take commitment and hard work to overcome the numerous challenges including a number of organisational constraints. There were, however, differing interpretations of what was required to attain BFHI accreditation with the potential that misinterpretation could hinder implementation. A model described by Greenhalgh and colleagues on adoption of innovation is drawn on to interpret the findings.

CONCLUSION

Despite strong support for BFHI, the principles of this global strategy are interpreted differently by health professionals and further education and accurate information is required. It may be that the current processes used to disseminate and implement BFHI need to be reviewed. The findings suggest that there is a contradiction between the broad philosophical stance and best practice approach of this global strategy and the tendency for health professionals to focus on the ten steps as a set of tasks or a checklist to be accomplished. The perceived procedural approach to implementation may be contributing to lower rates of breastfeeding continuation.