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Base de datos de evaluación

Evaluation report

2001 ZAM: Report on the Assessment of the Baby Friendly Hospital Initiative

Author: National Food and Nutrition Commission

Executive summary


The Baby Friendly Hospital Initiative (BFHI) activities in Zambia started soon after the Innocenti Declaration of 1992 to promote, protect and support breast feeding. These activities have been undertaken under the auspices of a National Breast Feeding Program formally established in 1993 to facilitate the attainment of the BFHI and to build up a resource center to sustain BFHI activities. Based at the National Food and Nutrition Commission (NFNC) since 1994, the program has received and continues to receive tremendous financial, technical and other support from UNICEF. Some support was also received from WHO, IBFAN - Africa and USAID/BASICS as well as several local and international non-governmental organizations (NGOs). Among the programs, notable successes have been the declaration of 40 health facilities (31 hospitals and 9 maternity units) as Baby Friendly, the drafting of a National Breast Feeding Policy and the development of a National Code of Marketing of Breast Milk Substitutes.

Purpose / Objective

With this background, it was felt that there is a need to evaluate the process of the implementation of the many activities that have been undertaken in implementing the BFHI. The study was executed by a team of consultants contracted by the NFNC under the sponsorship of UNICEF.
- To examine the breastfeeding situation for mothers and babies in selected health facilities designated Baby Friendly and non-Baby Friendly
- To assess changes in hospital practices in relation to breastfeeding
- To assess changes in attitudes of staff and parents regarding key messages on exclusive breastfeeding
- To examine changes in morbidity patterns of children under 6 months in selected health facilities
- To examine the institutional/policy framework for implementing the BFHI


The evaluation study was conducted in 4 provinces and covered 8 health facilities in all, with 3 from the Copperbelt, 2 each from Lusaka and Southern and 1 from the Central province. Except for the Central province facility, all others had been declared Baby Friendly at least one year earlier. The Central province facility was included as a control. The selection of the sample facilities was basically purposive and took account of each facility's history as a baby friendly institution, including the perceived commitment of its personnel to breastfeeding promotion. The selection also considered available resources in terms of personnel, time and finances and recognised the need for a comparison of the results not only within the facilities themselves but also between them geographically (district, rural/urban and province).

The number of respondents interviewed in each category (national, facility, community) were selected according to the following guidelines:
- For all health facilities except the UTH and Kitwe Central Hospital, at least 10 mothers were to be interviewed in each of the subcategories: antenatal, postnatal, and mothers with children under 6 months of age. For the UTH and Kitwe Central, sample size would be at least 20 for each subcategory because of the large scale of their operations.
- At least two health personnel at management level and five or more at operations level (professional/technical).
- At least one focus group discussion each for mothers in the community, fathers in the community and, where they exist, mother support groups in each health facility's catchment area.

Key Findings and Conclusions

Breastfeeding, though considered as a natural, social and biological practice deeply rooted to culture, is now topical and has been placed on the agenda. Issues of breastfeeding are now being discussed by hospital facilities and the community.

All hospitals that were declared baby friendly are indeed baby friendly, some a year or more later. Key practices, such as adoption of rooming in 87% , skin contact 24%, exclusive breastfeeding 20%, Kangaroo Mother Care 5%, and the absence of well baby nurseries, are some of the positive changes since the introduction of BFHI. However, the practices still differ markedly in the facilities. Facilities such as Macha, Matero and Roan hospital had both the staff and community appreciating breastfeeding whereas central facilities such as Kitwe and UTH had practices that are not optimal. Kanyama and Thomson hospital had the poorest practice of the Initiative.

The Promotion, Protection and Support of breastfeeding in the successful facilities were closely associated with the attitude of the managers. Where the facilities are performing poorly, the attitude of staff was often negative from the highest level. In successful facilities, all members of the staff were actively involved. In poor practicing facilities, a select few were the owners of the program.

Exclusive breastfeeding is the current emphasis of the BFHI in Zambia. Appropriate complementary feeding and continued breastfeeding until 2 years is not often imparted with the exclusive breastfeeding message.

Inappropriate breast feeding practices are widespread among both hospital staff and mothers in the community. The initiation and attachment skills crucial for successful lactation were rarely imparted by staff or known by mothers. Almost all (95%) of first-time mothers had neither been shown how to position nor latch their babies. In more than 50% cases, even though mothers were given their babies within one hour of delivery, first time postnatal mothers will not have attempted to breastfeed in the 3-6 hours after delivery.

Insufficient milk was the commonly cited (30%) breast feeding problem by women. The problem was most common among women in urban areas who were not housewives.

A high proportion of mothers (56%) who come to facilities have heard of breast feeding and also correctly stated the benefits and usefulness of breast feeding. This knowledge was not complemented by skills.

The facility staff indicated an observed reduction in the prevalence of diarrhea especially before six months. However, the study was unable to link morbidity patterns and nutrition status to the benefits of breast feeding. This was mainly due to the design of the evaluation.

Mothers expressed a lack of anxiety if they were near their babies and staff stated that babies cried less. This, they said, aided recovery because of the emotional support and the lack of anxiety of separation. Most doctors felt that breast feeding gives the baby a healthier start in life and greatly reduces chances of diseases.

The relationship between mothers and facility staff were said to have improved with the BFHI. Mothers noted that nurses appeared more caring while encouraging breastfeeding.

None of all the surveyed facilities reported a referral system between clinics and mother support group (MSG) even though all of them reported having a mother support group.


Accreditation to the CBOH should require that all hospitals are Baby Friendly. This is based on the observed positive changes both to the communities and the facilities.

There is a need to develop a BFHI monitoring system. This can routinely be done by respective DHMTS, CBOH and independent institutions such NFNC. Support is necessary to those hospitals that are doing well as well as to those whose standards are falling.

The concept of BFHI should include the "essential nutrition interventions" contained in the minimum nutrition package so that it is not viewed in isolation of other important child survival messages. This will ensure that the approach is holistic.

There is a need to speed up the completion of a policy on breast feeding and HIV. To facilitate the development of firm policies and recommendations on breast feeding in light of HIV/AIDS, T.B., and other infections, there is an urgent need to widen discussions and include different professions (e.g. doctors, nurses, NGOs and Women's Groups).

There should be a more consistent, effective Information, Education and Communication (IEC) system. The principles of exclusive breast feeding and breast feeding in general should not only be targeted at mothers.

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Health - BFHI



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