Breastfeeding
The Breastfeeding Support and Promotion inBaby-Friendly Maternity Hospitals and Not-as-YetBaby-Friendly Hospitals in Russia L.V. ABOLYAN ABSTRACT Objective: The objective was to evaluate implementation of the WHO/UNICEF “Ten Steps to Successful Breastfeeding” as defined by the Baby-Friendly Hospital Initiative in eight ma-ternity hospitals in the Moscow region. Four maternity hospitals had been certified Baby-Friendly Hospitals (BFHs), the experimental group; and four maternity hospitals Not-as-Yet Baby Friendly, the control group (NBFHs). Methods: Maternal interviews and infant breastfeeding rates were the primary outcomes of the study. In total, 741 healthy postpartum women from the experimental and control group were interviewed: 383 and 358, respectively. Interviews were conducted over 5 months, from May to July 2004. In addition, an assessment of levels and trends in breastfeeding for the pe-riodof 1998 to 2003 was made for the area served by the BFHs and the NBFHs. Findings: Analyses of the questionnaires completed by the mothers found a positive effect of BFH practice on a number of parameters, such as an increased rate of in-hospital exclusive breastfeeding, mothers’ decisions concerning planned duration of breastfeeding, mothers’ and babies’ health, and maternal knowledge about the necessary measures in BFHs. Mothers ap-preciated baby-friendly changes, such as rooming-in, breastfeeding on baby’s demand, and taking care of their babies by themselves. The successful initiation of breastfeeding in the BFHs was shown to favor the promotion of breastfeeding among 1-year-old babies in the experimental areas. However, there were some shortcomings in the BFHs: frequent use of labor anesthesia; insufficient placing of new-bornson the mother’s abdomen, rooming-in, and initiating breastfeeding immediately; and a short length of “skin-to-skin” contact (30 minutes). The women in BFHs also observed the use of feeding bottles and dummies, and experienced some problems with breast health. Conclusions: BFH practices can increase breastfeeding rates as well as maternal satisfaction. However, shortcomings in the training and support for mothers, and limited help of the med-ical personnel were noted. It is recommended that BFHs pay attention to maintaining adher-ence to the criteria of the 10 steps of the Baby-Friendly Hospital Initiative. Since 2003 to con-trol the implementation of the Baby Friendly Initiative principles and sustain the progress in the hospitals designated as Baby Friendly reassessment of maternity hospitals is held in Russia in conformity with the requirements of WHO and UNICEF. INTRODUCTION THE WHO/UNICEF BABY-FRIENDLY HOSPI-TAL INITIATIVE (BFHI) has been promoted in the Russian Federation since 1996. The main principles of the Initiative are stated in WHO and UNICEF papers: Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services (1989), Global Strat-egy for Infant and Young Child Feeding, Infant and Young Child Feeding: A Tool for Assess-ing National Practices, Policies and Pro-grammes and in the revised BFHI materials.1–3 The Breastfeeding Support Center of the Min-istry of Health and Social Development of the Russian Federation coordinates the work of im-plementing the Ten Steps of the Initiative intothe practice of maternity hospitals. The Center works in close collaboration with the UNICEF Office in the Russian Federation. National specially trained experts evaluate and desig-nate hospitals as “Baby-Friendly Hospital’s” (BFHs). As of October 1, 2005, 208 maternity hospitals (wards) had been awarded BFH des-ignation. The number of deliveries assisted an-nually in these maternity facilities varies from 100 in the rural areas to about 5000 deliveries in larger cities. The number of deliveries that occur in the BFHs is about 16% of all births in Russia. The maternity hospital of Electrostal (Moscow Region) was the first maternity hospital in Russia to receive BFH designation in 1996. In total, there are 52 maternal facilities in the Moscow Region (MR). Since 1996, four have been des-ignated BFHs. Annually these five BFHs assist in 5660 deliveries, or 10.5% of all deliveries in the Moscow Region (MR). The MR is located in the central part of Rus-sia. It is a fairly successful region as far as so-cial status and the quality of medical servicesare concerned. The infant mortality rate in the MR is lower than average for Russia. In 2003 the infant mortality rate in the MR was 11.8 per 1000 infants, compared with 12.4 per 1000 in the Russian Federation as a whole. The assessment of the impact of the imple-mentation of the Baby-Friendly Hospital Ini-tiative into the practice of hospitals is of great interest. Some investigations show a long-terminfluence of the BFH Initiative on the duration of breastfeeding and the state of babies’ and mothers’ health 4–8 in addition to the immedi-ate impact on breastfeeding initiation. How-ever, the evaluation of women’s experiences and satisfaction with this approach is also very important. Such studies were completed in Norway and Russia in 2000 and 2002 in the framework of the joint Russian Norwegian project “Voices of Women in the Barents Re-gion.” 9,10 The results showed improvements in several indicators of breastfeeding practice as-sociated with BFHs designation. However, it was also shown that the BFH status did not guarantee sustained high level of standards of practice. Work to maintain the principles of this initiative must continue over time. The objective of this study was to assess women’s perceptions of the quality of medical services in the BFHs as well as to assess the breastfeeding practices and trends in the areas with and without BFHs. MATERIALS AND METHODS This study was carried out in eight maternity hospitals in the Moscow Region: four maternity hospitals with Baby-Friendly status (BFHs), the experimental group; and four maternity hospi-tals Not-as-Yet-Baby-Friendly (NBFHs), the control group. The maternity hospitals of the control group are similar to the maternity hos-pitals of the experimental group and have the same indices of quality of the obstetrical ser-vices, the same number of deliveries, and com-parable levels of participation. Mothers’ assessment of the medical services was conducted using a questionnaire. The questionnaire included 76 questions that were divided into six main units: general informa-tion about the mother, antenatal preparation for breastfeeding, delivery data, breastfeeding practices, mothers’ and babies’ health status, and the mother’s attitude toward the new prac-tices to protect and support breastfeeding in the maternity hospital. Health status was assessed by the mother. Maternal depression was as-sessed using a scale of depression adapted by T.I. Balashova,11 and recommended for use inscreening for very mild, moderate or severe forms of depression. The senior midwife was responsible for in-terviewing women in the maternity hospital. All the senior midwives of the eight maternity hospitals were trained in selection and ques-tionnaire administration techniques. They also helped mothers to complete the questionnaire, as necessary. The questionnaire was completed at discharge. One hundred consecutive women who met eligibility requirements were identi-fied from each facility. Inclusion criteria in-cluded: no maternal illness, infant Apgar scores 7, and birthweight 2500 g. Mothers were asked to complete the form anonymously, seal it in an unmarked envelope, and pass it to the midwife or put it into a special box. Comple-tion and submission of the form was consid-ered consent to participate. Altogether 383/400 forms were submitted in the BFHs (the exper-imental group) and 358/400 forms were sub-mitted in the NBFHs (the control group). A general description of the maternity hospitals, including numbers of annual deliveries, BFH date of designation, and the number of ques-tioned women is presented in Table 1. Data col-lection was completed from May to July 2004. An assessment of the levels and trends in breastfeeding for the period 1999 to 2003 for the experimental and control areas was carried out using data from the official statistics of the Min-istry of Health and Social Development of the Russian Federation. Children’s outpatient polyclinics are responsible for the annual collection of breastfeeding data in Russia among mothers of 1-year-old children. The statistical analysis of the questionnaire data was completed using SPSS 10.0 program for Windows.12 Normality of the characteristic distribution was determined using the Kolmogorov- Smirnov test. Descriptive statistics are presented. The Student Independent Samplest-test was used for the comparison of the means. BREASTFEEDING SUPPORT IN RUSSIA The senior midwife was responsible for in-terviewing women in the maternity hospital. All the senior midwives of the eight maternity hospitals were trained in selection and ques-tionnaire administration techniques. They also helped mothers to complete the questionnaire, as necessary. The questionnaire was completed at discharge. One hundred consecutive women who met eligibility requirements were identi-fied from each facility. Inclusion criteria in-cluded: no maternal illness, infant Apgar scores 7, and birthweight 2500 g. Mothers were asked to complete the form anonymously, seal it in an unmarked envelope, and pass it to the midwife or put it into a special box. Comple-tion and submission of the form was consid-ered consent to participate. Altogether 383/400 forms were submitted in the BFHs (the exper-imental group) and 358/400 forms were sub-mitted in the NBFHs (the control group). A general description of the maternity hospitals, including numbers of annual deliveries, BFH date of designation, and the number of ques-tioned women is presented in Table 1. Data col-lection was completed from May to July 2004. An assessment of the levels and trends in breastfeeding for the period 1999 to 2003 for the experimental and control areas was carried out using data from the official statistics of the Min-istry of Health and Social Development of the Russian Federation. Children’s outpatient polyclinics are responsible for the annual collection of breastfeeding data in Russia among mothers of 1-year-old children. The statistical analysis of the questionnaire data was completed using SPSS 10.0 program for Windows.12 Normality of the characteristic distribution was determined using the Kolmogorov- Smirnov test. Descriptive statisticsare presented. The Student Independent Sam-ples t-test was used for the comparison of the means. RESULTS The mothers who completed the question-naire in the BFHs and NBFHs did not differ sig-nificantly in most characteristics (Table 2). The average age was 25.9 versus 25.7 years (p 0.05), respectively. Most mothers had sec-ondary or higher education (11 years and more; 91.1% versus 94.1%). About one-third of moth-ers had 16 to 17 years of education (32.1% ver-sus 35.7%). More than 70% of women were married, 16% to 18% had partners, and 8% to 9% were unmarried. More than half of all women were primiparas (62.5% versus 67.3%). The average number of children in the families of both groups was 1.4 and there was no sta-tistical difference in the sex of the infants.
The women of the NBFHs group had higher in-come levels (28.2% versus 46.0%), with incomes below the living wage. All of the respondents breastfed their babies during their stay in the maternity hospital. Table 3 presents the findings from the ques-tionnaires.There was no statistical difference in weeks of gestation at registration for ante-natal care (10.4 versus 11.3 weeks). The num-ber of caesarian sections was 14.7% in the BFHs and 16.2% in the NBFHs. Maternal anesthesia for delivery was commonly used in both BFHs and NBFHs (62.3% and 54.6%). The duration of stay in the hospital was similar for both groups (5.0 versus 5.2 days). Differences in breastfeeding practices were found between the BFHs and the NBFHs. In the BFHs more women attended antenatal breast-feeding education sessions: 44.9% versus 31.5% in maternity consultations and 35.8% versus
BREASTFEEDING SUPPORT IN RUSSIAмм
10.4% in maternity hospitals. In BFHs babies were laid on the mother’s abdomen more often than in NBFHs (73.4% versus 57.6%), skin to skin contact lasted at least 30 minutes (34.0% versus 1.7%), and mothers and babies roomed-in (93.4% versus 51.5%). In the BFHs, the me-dian time for initiation of breastfeeding was in the first 2 hours after delivery; in the NBFHs the median was within the first 12 hours, and 25% did not initiate breastfeeding within the first 24 hours after delivery. The medical staff of BFHs helped women breastfeed more often than in NBFHs (93% versus 75.5%); in BFHs newborns were less likely to receive artificial feeding and a bottle (7.4% versus 58.0%), and dummies were not used as often (4.0% versus 18.1%). In NBFHs fewer women knew whether or not staff had given artificial feeds or bottles to their babies (9.4% versus 3.7%), or whether dummies were used (24.8% versus 2.4%). An important outcome is that 88.9% of babies in BFHs and only 32.6% in NBFHs received breastfeeding only (exclusive breastfeeding) from birth until discharge. Women from BFHs noted that lactation pro-ceeded better, in comparison with those from NBFHs. Milk appeared on the day 2.9 versus 3.2 (p 0.01). The majority of the women from BFHs reported that they had enough milk for their babies (74.0% versus 50.3%) and a smaller proportion did not know whether they had enough milk (20.1% versus 36.4%). In BFHs there were fewer breast problems, such as nipple pain during breastfeeding (21.9% versus 32.0%) and breast engorgement (4.7% versus 11.0%). Nevertheless, almost half of the women in both experimental and control groups reported some breast problems. Most of the women in BFHs and NBFHs wished to breastfeed their babies after dis-charge. They said, “I will surely breastfeed my baby” (95.1% to 89.9%) and, “I will breastfeed if I can” (4.9% to 9.2%), and only 0.8% of women from NBFHs planned to give their ba-bies artificial feeding. The planned length of breastfeeding was 11.4 months in the control group, but it was longer among the women in the BFHs: 12.3 months (p 0.05). No significant differences were seen in the reported health status of the respondents and their babies, with 90% in both groups reporting good health. Depression was diag-nosed by screening as 2.3% in each group and 1% of women were screened as mildly de-pressed in each group. An important measure of adequate feeding and good care during maternity stay is infant weight change. Weight loss at the discharge was significantly lower among the BFHs ba-bies: 1.3% versus 3.0% (p 0.001). The av-erage length of stay was approximately 5 days for both groups. The assessment of maternal attitudes in both groups revealed that breastfeeding support was very important. However more women from BFHs estimated such measures as early attachment to breast (94.0% versus 89.3%), rooming-in (95.3% versus 77.3%), feeding on baby’s demand (95.3% versus 87.1%) and the possibility of taking care of their babies them-selves (95.5% versus 82.5%) as “important” and “very important.” Breastfeeding rates in the experimental and control groups in the period of 1999 to 2003 are shown in Figure 1. The implementation of the Baby-Friendly Hospital Initiative in the practice of maternity hospitals is associated with in-creases in the prevalence of breastfeeding among infants. In the period 1999 to 2003, a positive trend in breastfeeding was registered in the experimental areas of the MR. The prevalence of breastfeeding in these areas increasedby 50% among babies 6 to 12 months (from 20.7% to 31.2%) in the BFH area, but in the control area, the increase was only 24% (from 15.6% to 19.3%) among babies 6 to 12 months.
BREASTFEEDING SUPPORT IN RUSSIA DISCUSSION This study confirmed that the majority of Russian women in these areas begin breast-feeding in the maternity hospitals.13,14 Al-though the Baby-Friendly Hospital Initiative has under development in the Moscow Region since 1996, only four maternity hospitals out of 52 have the WHO/UNICEF Baby Friendly Hospital Designation, and only 10.5% of annual deliveries in Moscow Region are in these BFHs. There are significant differences in the practice of breastfeeding protection and support in BFHs and NBFHs. The BFHs include a great number of pregnant women in breastfeeding education, more often use practices such as immediate skin-to-skin contact (laying a newborn on mother’s abdomen), not less than 30 minutes skin-to-skin contact, early attachment to the breast in the de-livery room, and rooming-in. The first breast-feeding is in the postpartum room during the first hours after delivery in the BFHs, whereas in other hospitals medical personnel more often help mothers during their first breastfeed. The questionnaire showed that 89% exclusively breastfed from birth until discharge. However, there are many issues to address in the work of BFHs, including frequent use of anaesthetic agents (62%), less than universal immediate skin-to-skin contact (73%), a short duration of skin-to-skin contact (30 minutes; 66%), and less than universal rooming-in and early initiation of breastfeeding (63%). Women in the BFHs ob-served the use of feeding bottles (7.0%) and dum-mies (4.0%), and many experienced preventable breast problems: pain during breastfeeding (21.9%), cracks of the nipples (15.6%), and breast engorgement (4.7%). This means that there is room for improvement in the education of med-ical personnel and support for mothers. Nonetheless, it was evident also that the practices of the BFHs in supporting breast-feeding had some advantages in comparison with those of the NBFHs. These new practices influenced early lactation as well as the under-standing and perception of milk sufficiency, breast health, and breastfeeding decisions. An important impact of BFHs was that appropri-ate breastfeeding and good medical care re-sulted in decreased infant weight loss during the maternity stay. No differences in depression were revealed between the BFHs and NBFHs. A slight de-pression or subdepressive state was found in only 3.0% of both groups. Thus, fears of some doctors in the MR that rooming-in and breast-feeding on the baby’s demand would exhaust and, hence, depress women were not con-firmed by the results of this study. Most women from experimental and control groups appreciated the implementation of “The Ten Steps” for breastfeeding support and protection. In the BFHs, however, more women rated the following as “important” and “very important” measures: rooming-in (95.0% ver-sus 77.0%), breastfeeding on demand (95% ver-sus 87%), and the possibility of taking care of their babies themselves (95% versus 82%). Such appreciationn would seem to have resulted from the educational and supportive work of med-ical personnel during pregnancy, delivery, and maternity stay in the hospital. A sustained increase in the prevalence of breastfeeding among 1-year-old babies has been observed for the last 5 years. In compari-son with the control areas, the prevalence of breastfeeding in the experimental areas of the MR was higher and experienced a greater per-centage increase. CONCLUSION These findings lead to the conclusion that there is a positive effect of BFH practice on a number of parameters, such as lactation, increasing of the rate of exclusive breastfeeding from birth until discharge, mothers’ and ba-bies’ health, mothers’ decision regarding long-term breastfeeding. Having proper antenatal education, and being well-informed about the necessary measures in BFHs, mothers highly appreciate rooming-in, breastfeeding on baby’s demand, and taking care of their babies by themselves. It is reasonable to assume that the implementation of the BFHs was associated with the increases in breastfeeding among in-fants in the experimental areas. All the NBFHs have put into practice some elements of the BFH Initiative (e.g., antenatal breastfeeding education, early attachment, rooming-in, the assistance of medical personnel during breastfeeding). These hospitals also may be considered for BFH designation. At the same time BFHs also must make efforts to en-sure ongoing adherence to the Ten Steps crite-ria for ongoing positive impact.15 One limitation of the study design is the con-venience sampling; however, the adequate sample size and common implementation seem to have overcome this possible problem. This study reconfirms the importance of sus-tained attention to all of the criteria of the BFHI, initiated in the MR in 2003, with ongoing qual-ity assurance and reassessment of maternity hospitals in Russia in conformity with the re-quirements of WHO and UNICEF.
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