Ten steps for successful breast-feeding: assessment of hospital performance, its determinants and planning for improvement

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.

Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design

BACKGROUND

Smoking in pregnancy and/or not breastfeeding have considerable negative health outcomes for mother and baby.

AIM

To understand incentive mechanisms of action for smoking cessation in pregnancy and breastfeeding, develop a taxonomy and identify promising, acceptable and feasible interventions to inform trial design.

DESIGN

Evidence syntheses, primary qualitative survey, and discrete choice experiment (DCE) research using multidisciplinary, mixed methods. Two mother-and-baby groups in disadvantaged areas collaborated throughout.

SETTING

UK.

PARTICIPANTS

The qualitative study included 88 pregnant women/recent mothers/partners, 53 service providers, 24 experts/decision-makers and 63 conference attendees. The surveys included 1144 members of the general public and 497 health professionals. The DCE study included 320 women with a history of smoking.

METHODS

(1) Evidence syntheses: incentive effectiveness (including meta-analysis and effect size estimates), delivery processes, barriers to and facilitators of smoking cessation in pregnancy and/or breastfeeding, scoping review of incentives for lifestyle behaviours; (2) qualitative research: grounded theory to understand incentive mechanisms of action and a framework approach for trial design; (3) survey: multivariable ordered logit models; (4) DCE: conditional logit regression and the log-likelihood ratio test.

RESULTS

Out of 1469 smoking cessation and 5408 breastfeeding multicomponent studies identified, 23 smoking cessation and 19 breastfeeding studies were included in the review. Vouchers contingent on biochemically proven smoking cessation in pregnancy were effective, with a relative risk of 2.58 (95% confidence interval 1.63 to 4.07) compared with non-contingent incentives for participation (four studies, 344 participants). Effects continued until 3 months post partum. Inconclusive effects were found for breastfeeding incentives compared with no/smaller incentives (13 studies) but provider commitment contracts for breastfeeding show promise. Intervention intensity is a possible confounder. The acceptability of seven promising incentives was mixed. Women (for vouchers) and those with a lower level of education (except for breastfeeding incentives) were more likely to disagree. Those aged ≤ 44 years and ethnic minority groups were more likely to agree. Agreement was greatest for a free breast pump and least for vouchers for breastfeeding. Universal incentives were preferred to those targeting low-income women. Initial daily text/telephone support, a quitting pal, vouchers for > £20.00 per month and values up to £80.00 increase the likelihood of smoking cessation. Doctors disagreed with provider incentives. A 'ladder' logic model emerged through data synthesis and had face validity with service users. It combined an incentive typology and behaviour change taxonomy. Autonomy and well-being matter. Personal difficulties, emotions, socialising and attitudes of others are challenges to climbing a metaphorical 'ladder' towards smoking cessation and breastfeeding. Incentive interventions provide opportunity 'rungs' to help, including regular skilled flexible support, a pal, setting goals, monitoring and outcome verification. Individually tailored and non-judgemental continuity of care can bolster women's capabilities to succeed. Rigid, prescriptive interventions placing the onus on women to behave 'healthily' risk them feeling pressurised and failing. To avoid 'losing face', women may disengage.

LIMITATIONS

Included studies were heterogeneous and of variable quality, limiting the assessment of incentive effectiveness. No cost-effectiveness data were reported. In surveys, selection bias and confounding are possible. The validity and utility of the ladder logic model requires evaluation with more diverse samples of the target population.

CONCLUSIONS

Incentives provided with other tailored components show promise but reach is a concern. Formal evaluation is recommended. Collaborative service-user involvement is important.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012001980.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

[Support of breastfeeding by health professionals: integrative review of the literature]

OBJECTIVE

To review the literature in order to evaluate how health professionals promote and support breastfeeding.

DATA SOURCES

Studies from the following databases were retrieved: Scopus, PubMed, Medline, Lilacs, SciELO, Web of Science and Cumulative Index to Nursing and Allied Health Literature (Cinahl). The descriptors "breastfeeding", "professional role" and "patient care team" were used in the research. The review was limited to articles in Portuguese, Spanish, and English published between 1997 and 2013.

DATA SYNTHESIS

The search retrieved 1,396 studies, 18 of which were selected for being directly relevant to the main question. The review showed that breastfeeding is a challenge for health professionals, regardless of their specialization, as they have to face a demand that requires skill and sensibility, for which they are not prepared. Health professionals have considered breastfeeding a purely instinctive and biological act. Moreover, it is noticeable that many of them possess theoretical expertise on the subject, but lack the practical skills.

CONCLUSIONS

Health professionals need to be better trained to work on promoting breastfeeding, whether by health and medical schools or by healthcare administrators, in order to consolidate multiprofessional teams committed to maternal-infant health.

Barriers, facilitators, and recommendations related to implementing the Baby-Friendly Initiative (BFI): an integrative review

Despite growing evidence for the positive impact of the Baby-Friendly Initiative (BFI) on breastfeeding outcomes, few studies have investigated the barriers and facilitators to the implementation of Baby-Friendly practices that can be used to improve uptake of the BFI at the local or country levels. This integrative review aimed to identify and synthesize information on the barriers, facilitators, and recommendations related to the BFI from the international, peer-reviewed literature. Thirteen databases were searched using the keywords Baby Friendly, Baby-Friendly Hospital Initiative, BFI, BFHI, Ten Steps, implementation, adoption, barriers, facilitators, and their combinations. A total of 45 English-language articles from 16 different countries met the inclusion criteria for the review. Data analysis was guided by Cooper's five stages of integrative research review. Using a multiple intervention program framework, findings were categorized into sociopolitical, organizational-level, and individual-level barriers and facilitators to implementing the BFI, as well as intra-, inter-, and extraorganizational recommendations for strengthening BFI implementation. A wide variety of obstacles and potential solutions to BFI implementation were identified. Findings suggest some priority issues to address when pursuing Baby-Friendly designation, including the endorsements of both local administrators and governmental policy makers, effective leadership of the practice change process, health care worker training, the marketing influence of formula companies, and integrating hospital and community health services. Framing the BFI as a complex, multilevel, evidence-based change process and using context-focused research implementation models to guide BFI implementation efforts may help identify effective strategies for promoting wider adoption of the BFI in health services.

Compliance with Baby-Friendly policies and practices in hospitals and community health centers in Quebec

BACKGROUND

Since 2001, Quebec's ministry of health and social services has prioritized implementation of the Baby-Friendly Initiative (BFI), which includes the original hospital initiative and its expansion to community services.

OBJECTIVE

The objective was to document across the province compliance with the BFI's Ten Steps to Successful Breastfeeding in hospitals, Seven Point Plan in community health centers (CHCs), and International Code of Marketing of Breast-Milk Substitutes (Code).

METHODS

Using managers/staff, mothers, and observers, the author measured the extent of implementation of indicators formulated for each step/point and the Code, based on the revised WHO/UNICEF recommendations.

RESULTS

Mean compliance scores in Quebec were 3.13 for 140 CHCs (range, 0 to 7) and 4.54 for 60 hospitals/birthing centers (range, 0 to 10). The mean compliance score for the Code was 0.69 for both CHCs and hospitals/birthing centers. The evaluation documented marked variations in implementation level for each of the steps/points and the Code. Also, managers/staff, mothers, and observers differed in their report of BFI compliance for most steps/points and the Code. Facilities that had applied for or obtained BFI designation demonstrated higher compliance with the BFI than those that had not.

CONCLUSIONS

Results disseminated to participating organizations allowed comparisons on a regional/provincial perspective and in relation to BFI-designated facilities. Furthermore, this first portrait of BFI compliance in Quebec provided provincial, regional, and local health authorities with valuable information that can be used to bring about policy and organizational changes to achieve the international standards required for Baby-Friendly certification.

Measuring compliance with the Baby-Friendly Hospital Initiative

OBJECTIVE

The WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI) is an effective strategy to increase breast-feeding exclusivity and duration but many countries have been slow to implement it. The present paper describes the development of a computer-based instrument that measures policies and practices outlined in the BFHI.

DESIGN

The tool uses clinical staff/managers' and pregnant women/mothers' opinions as well as maternity unit observations to assess compliance with the BFHI's Ten Steps to Successful Breastfeeding (Ten Steps) and the International Code of Marketing of Breastmilk Substitutes (Code) by measuring the extent of implementation of two to fourteen indicators for each step and the Code. Composite scores are used to summarize results.

SETTING

Examples of results from a 2007 assessment performed in nine hospitals in the province of Québec are presented to illustrate the type of information returned to individual hospitals and health authorities.

SUBJECTS

Participants included nine to fifteen staff/managers per hospital randomly selected among those present during the interviewer-observer's 12 h hospital visit and nine to forty-five breast-feeding mothers per hospital telephoned at home after being randomly selected from birth certificates.

RESULTS

The Ten Steps Global Compliance Score for the nine hospitals varied between 2.87 and 6.51 (range 0-10, mean 5.06) whereas the Code Global Compliance Score varied between 0.58 and 1 (range 0-1, mean 0.83). Instrument development, examples of assessment results and potential applications are discussed.

CONCLUSIONS

A methodology to measure BFHI compliance may help support the implementation of this effective intervention and contribute to improved maternal and child health.

Becoming baby-friendly in Spain: a quality-improvement process

AIM

To describe the implementation process and effect of a quality-improvement intervention aimed at achieving compliance with the Baby-friendly Hospital Initiative (BFHI).

METHODS

We conducted a prospective study of the development and evaluation of a quality-improvement intervention at the Yecla Hospital, Spain. A random sample of 1273 infants born in the hospital was followed up in primary care centres between 1997 and 2005. The study interventions were process-oriented training, audit and feedback, quality-improvement cycles and provision of breastfeeding support resources. The main outcome measures were changes in compliance with the Global Criteria for the BFHI and breastfeeding rates before, during and after the intervention.

RESULTS

Compliance with the Global Criteria increased progressively, and in 2004 all criteria were met. The median duration of breastfeeding went up gradually from the start of the intervention. The likelihood of being breastfed at different ages among infants born in 2005 was between 45% [odds ratio (OR) 0.55; 95% confidence interval (CI) 0.38-0.79] and 86% (OR 0.14; 95% CI 0.09-0.20) higher than among infants born in 1997.

CONCLUSION

Quality-improvement interventions based on participation, training, audit and feedback of information, and provision of resources are useful for the implementation of the BFHI, which is associated with a significant increase in breastfeeding rates.

Breastfeeding practices in baby friendly hospitals of Indore

An interview based cross sectional study was conducted in two of the designated Baby Friendly Hospitals of Indore in the year 2008. None of the hospitals were having a written breastfeeding policy, which is routinely communicated to all the health workers and no regular training regarding the Programme was being imparted. There is a need to develop a BFHI Monitoring System to ensure that the status is kept in check. Training regarding essential Criteria of BFHI should be there for all the staff.

Implementing Baby Friendly Hospital Initiative policy: the case of New Zealand public hospitals

Background

Studies show that when the Baby Friendly Hospital Initiative (BFHI) is implemented breastfeeding rates increase. However, there are likely to be various barriers to BFHI implementation. This article reports on an empirical study of government-directed BFHI implementation in the New Zealand public hospital system. It focuses primarily on the barriers encountered through implementing the first Two Steps of the BFHI: developing BFHI policy and communicating it to staff; and providing necessary staff training.

Methods

Qualitative interview data were collected from six lactation consultants. These interviewees emerged via a purposive sample of public hospitals that represent the full range of New Zealand public hospitals. Using a content analysis technique, key themes were drawn from the transcribed interview data.

Results

Analysis revealed eight themes: the hospitals were in varying stages of BFHI policy development; hospital policy was not necessarily based on government policy; hospital policies were communicated in differing ways and dependent on resources; factors outside of hospital control impacted on capacity to improve breastfeeding rates; and complex organisational matters pose a barrier to educating personnel involved in the birthing process.

Conclusion

The findings of this study provide empirical support for prior articles about the process of BFHI policy development and implementation. The study also shows that implementation is multi-faceted and complex.

[Assessment of the promotion of breastfeeding in public and private maternities of São Paulo city, Brazil]

OBJECTIVE

The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) carried out a study to compare and evaluate the practices of protecting, promoting and supporting breastfeeding in public and private hospitals using the "ten steps" of the Hospital Initiative (BFHI) as a reference parameter.

METHODS

Forty-five hospitals of the municipality of São Paulo participated in the study. Data on the practices of infant feeding were collected by interviewing nurseries' supervisors of all public hospitals (26), and from a random sample of private hospitals (19), corresponding to a third of the total, during the years 1996-1997.

RESULTS

More than a quarter of the public hospitals and more than one third of the private hospitals did not comply with any of the BFHI steps. Seven of the "ten steps" were observed in only two public hospitals. In general, practices of protection, promotion, and support of breastfeeding were seen at a higher frequency in public hospitals.

CONCLUSIONS

The present study shows that practices considered detrimental to the onset and progressing of breastfeeding - unnecessary separation of the mother and her newborn, restrictions regarding the length of time and frequency of breastfeeding, use of pre-lacteal foods and supplements - are still quite frequently observed in public and private hospitals within the city of São Paulo. Given the benefits of breastfeeding for both the mother's and their children's health, and the important role maternities play for an early and successful onset of breastfeeding, it is paramount that the BFHI patterns be adopted by hospitals within the municipality of São Paulo.

Evidence-based care and the breastfeeding couple: key concerns

Optimal health care is based on evidence that a) no harm is done when that care is provided and that b) the care provided assists in the prevention of further problems or the resolution of the presenting problem. Too often, care provided to lactating mothers and their breastfeeding offspring lacks evidence supportive of the techniques used or care provided. This article addresses 10 common hospital-based practices and reviews documented evidence related to their effect on breastfeeding success. Concepts pertaining to the breasts and breastfeeding that require incorporation into the educational offerings of current and future health care providers are also identified.