2002 JAM: Evaluation of the Baby Friendly Hospital Initiative and the Breastfeeding Programme
Author: Hamilton, P.
The Government of Jamaica, as a signatory to the Innocenti Declaration and the International Code of Marketing of Breastmilk Substitutes, has, through the Ministry of Health (MOH), sought to recommit its efforts to the promotion of full breastfeeding for 4-6 months by the adoption of the BFHI, training of health professionals in lactation management and the continued promotion of breastfeeding in health centers. These efforts have had limited outcome as there has been no significant increase in the national breastfeeding rate. In 1998, exclusive breastfeeding rate at six weeks was 54 percent (Monthly Clinic Summary Report, Ministry of Health, 1998). The findings of national surveys of the prevalence of breastfeeding show that breastfeeding is initiated by more than 90 percent of mothers. This level is, however, not sustained for the recommended period and there is wide variation in duration. The ongoing challenge faced by the Ministry is to determine the most successful means to support and sustain the initiation level of breastfeeding so that the optimum benefits will accrue to infants and their mothers in the first instance.
The evaluation has as its major aim the assessment of the impact of the Baby Friendly Hospital Initiative and the lactation management programme, to identify its strengths and weaknesses.
The specific objectives are to:
- Assess the process and impact of the National Intersectoral Lactation Management Commitment in relation to its stated roles and functions
- Evaluate staff training in lactation management
- Assess the implementation and status of the baby friendly initiative in selected accredited baby friendly hospitals
- Ascertain the degree of standardization of breastfeeding data collection and recording in health care facilities
- Investigate among selected target groups, adolescents, men, pregnant women (antenatal), breastfeeding mothers (postnatal), health care workers and influential persons their knowledge, opinion, beliefs, support for breastfeeding, breastfeeding practices and experience.
The study utilized a combination of documentary, quantitative and qualitative approaches. Documentary research was undertaken in relation to international and national policy documents, lactation management curriculum, training materials and the Monthly Clinic Summary Reports 1990–1999.
The sample of antenatal and postnatal clients, and health service providers was drawn from 14 health care facilities, which included 3 hospitals and 11 health centres in the parishes of Kingston and St. Andrew, St. Catherine, Clarendon and Trelawny. A total of 674 persons comprised of 262 antenatal clients, 260 postnatal and 152 health care providers were interviewed.
The quantitative component of the study utilized three questionnaires developed for the target groups of antenatal and postnatal clients, and health care service providers. A wide range of health care providers were targeted, which included medical doctors; matrons staff nurses, public health nurses, enrolled assistant nurses, breastfeeding promoters and community health aides. The survey sites were selected in collaboration with the Ministry of Health and a rural urban distinction was maintained. All respondents were selected in the health facility during antenatal and postnatal clinic sessions.
The qualitative component of the study utilized focus group discussions (FGDs) among the selected target groups of adolescents, men, pregnant women (antenatal), breastfeeding mothers (postnatal), men and influential persons. A total of 20 FGDs were conducted, 5 in each of the study parishes. Focus group discussions were recorded for content analysis.
Findings and Conclusions:
The findings indicate that the Ministry of Health, Jamaica has directed its health delivery system to promote and deliver services to ante and postnatal women to encourage them to breastfeed their infants exclusively for 4- 6 months. A variety of approaches have been used at different levels to institutionalize exclusive breastfeeding as a norm. Efforts include the development of a breastfeeding policy, training of health professionals, production and distribution of educational materials, public promotion of breastfeeding, advocacy and community mobilization.
These efforts have had some impact, in that mothers are more aware and believe in the benefits of breastfeeding to their infants. The support services, however, to sustain the initial interest and willingness among mothers to continue breastfeeding are not at the required strength and comprehensiveness to support and maintain the initial high level of breastfeeding. It is a small proportion of mothers who report getting help with breastfeeding after leaving the maternity institutions. The assistance and support of the trained and experienced health care providers are critical facilitators for breastfeeding.
Among all target groups in the study, it is unanimous that breastfeeding is best feed for infants. It is also very clear that men are willing supporters of breastfeeding and want their partners to breastfeed. Irresponsibility and poor preparation for motherhood among mothers were often noted as reasons for limited or inadequate breastfeeding. More intense preparation is obviously required to prepare mothers for breastfeeding and to inform their partners on how they can improve their support for breastfeeding. This support is underscored by the nagging problem of sore nipples and pain experienced by most breastfeeding mothers.
The main issue with breastfeeding among the respondents (excluding health care providers), despite its wide acceptance, is whether breastfeeding should be done exclusively or combined with other foods, at what age and for how long. Related to this issue is the question as to how well breastmilk meets the nutritional needs of a growing child without supplementation. This issue of exclusive breastfeeding needs to be consistently explained and promoted with evidence that addresses each of the benefits to infants and mothers in a convincing and culturally sensitive way. Women are already convinced of the benefits of breastfeeding to their infants, which must be reinforced, but the specific benefits to them, as women need to be more highlighted.
As reflected in the surveys and the Focus Group Discussions (FGDs), the overwhelming majority of postnatal mothers initiated breastfeeding but less than half (42.7 percent) were breastfeeding exclusively. As seen from the data, there have been various strains of resistance regarding exclusive breastfeeding for more than 3-4 months. This must be noted in the context of insufficient professional support to maintain breastfeeding and limited promotion of the expression and storage of breastmilk.
These resistant areas, as noted in the text, included issues like working mothers, time constraints, physical attributes and the perception about the nutritional contribution for the baby. These positions have support among partners and other relatives. The constraints, both personal and institutional, that are faced by women to breastfeed exclusively for 4-6 months need to be considered and strategies developed to address them. Beyond the individual woman, there are some practical and institutional issues involved in relation to physical facilities and working conditions to facilitate exclusive breastfeeding that are outside the direct control of the women. These will require both the development and implementation of public policy measures.
A major area of resistance has been the expressing of breastmilk to ensure exclusive breastfeeding. This resistance has often been based on previous experiences with this practice and or negative information about the procedure from other sources. Possibly, more education and skill development will increase exposure to, and heightened awareness about, breastmilk expression. Demonstrations are needed with respect to storage and the length of time that the milk remains “fresh” without refrigeration to increase the acceptance of expressing and storing breastmilk.
Moreover, respondents’ view that intentions to breastfeed are hampered by the poor nutritional status of some mothers needs to be addressed. Possibly, a broadened food assistance programme for “needy” pregnant and lactating mothers to enhance their nutritional status could be considered. As reflected in the data, breastfeeding is linked to “drawing down mother,” therefore the expansion of the food stamp programme should be an encouragement for some mothers to practice exclusive breastfeeding.
The level of coverage and intensity of the lactation management training appears to be inadequate to keep staff motivated and continuously updated on how to address breastfeeding as an integral, critical and fundamental aspect of ante and postnatal care. There is some measure of unevenness in the delivery of breastfeeding information and services and this points to the need for greater standardization among health care providers.
Reports from health care providers and Ministry officials identify diminishing resources being available for the maintenance of the breastfeeding initiative and, as a consequence, there has been a lapse in the programme. The Ministry needs to refocus its efforts to regain the lost ground and to push forward to achieve increased levels of exclusive breastfeeding.
The strategies for the implementation of the breastfeeding programme are already detailed in various international and local documents, which are available in the Ministry of Health. What is therefore required is for resources to be allocated to facilitate their full implementation.
It appears that for the breastfeeding initiative to achieve its intended goals, a certain level of synergy is needed between health care providers, the clients and the community, so that each supports and reinforces the other. In order to do this, there must be a strong focal point in the main stakeholders domain, which is the Ministry of Health, to energise and drive the process.
The overall recommendation to the Ministry of Health is that the 4 specific actions outlined in the Innocenti Declaration of 1995 with respect to the following should be fully implemented:
- Appointment of a breastfeeding co-ordinator
- Ensure that every facility providing maternity services fully practices all Ten Steps to Successful Breastfeeding
- Give effect to the principles and aims of all Articles of the International Code of Marketing, and;
- Enact legislation to protect the breastfeeding rights of working women and establish the means for its enforcement
There are further additional recommendations in the areas of Training, Budgetary Allocation, Monitoring and Evaluation, and Breastfeeding Support Services.
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