Effect on rates of breast feeding of training for the Baby Friendly Hospital Initiative

Introduction

Exclusive breast feeding for about six months has many advantages,1 but its prevalence in infants less than 4 months is low in many countries.2 There is some evidence that the implementation of the “ten steps to successful breast feeding” of the Baby Friendly Hospital Initiative will lead to an increase in breast feeding.3 Such policy requires changes in healthcare practices to be brought about by properly trained health professionals. Unfortunately, their knowledge and competence was always considered below standard when tested,4-10 and the effects of training have rarely been assessed.11 Of the courses available from Unicef and WHO, 12 13 the latter was shown to improve knowledge, clinical, and counselling skills.14 Little is known, however, on the effect of training on hospital practices.15-17 A recent paper showed the effectiveness of the Unicef course on breastfeeding rates in Belarus, where maternity hospital practices are similar to those in Western Europe 20 to 30 years ago.18

We examined the effects of the Unicef course on hospital practices, knowledge of health workers, and breastfeeding rates at discharge and three and six months later in a high income country.

Background

Assessment of problems and strategy for change

Effects of change

All hospitals improved their compliance with the ten steps, from one to three steps before to six to ten steps after training. Improvement was easier for steps four to nine—that is, for hospital routines. The performance was worse on steps one (written guidelines), two (training at least 80% of staff), and ten (community support). Table 1 shows the results of the assessment at various times. At phase one we found materials featuring names, logos, or brands of infant food manufacturers in only one hospital (in group 1); these materials were removed after training. We also found messages contrary to the ten steps in two hospitals of group 1. Messages in favour were present in one hospital of group 1 and two of group 2. By the third phase all the hospitals were displaying favourable messages.

Knowledge of health workers improved after training. The mean score, weighted by age, year of graduation, and years working in the same position, went up from 0.41 to 0.66 to 0.72 in group 1 and from 0.53 to 0.53 to 0.75 in group 2 at the three phases, respectively. The response rate was stable in group 2 (52-55% of trainees) but dropped by half (from 66% to 34-36%) in group 1 after phase one. Most respondents were women (between 81% and 91% in different groups); most men were physicians (89%) and most women were nurses and midwives (75%). All health professionals were represented, with more nurses (34%-59%) and midwives (13%-24%) than obstetricians (5%-19%) and paediatricians (4%-26%). The mean age varied between 37 and 43 years, with degrees obtained between 1954 and 1994.

Table 2 shows some features of the enrolled mother and baby pairs, and some feeding practices during their stay in hospital. The difference in sample size between phase one and two in group 2 is due to the reduction from four to three hospitals (but exclusion of data from the fourth hospital did not change the results). The difference between phase two and three is due to the loss of 60 data collection forms. Characteristics of mothers and infants in both groups were similar, except for slight differences in age, parity, and employment. These differences were taken into account in the standardisation of breastfeeding rates and in the logistic regression model.

Table 3 shows the crude rates of exclusive, predominant, complementary, and no breastfeeding at discharge (recall period since birth) and at three and six months (recall period of 24 hours). The standardised rates do not differ significantly (P=0.34). Exclusion of the hospital withdrawn from group 2 after phase one does not change the results. In both groups the differences before and after training in exclusive breast feeding at discharge, full breast feeding at three months, and any breast feeding at six months are significant (at least P<0.05).

Four factors were significantly associated with exclusive breast feeding at discharge: first breast feed within one hour, rooming in (where the baby stays in the same room as the mother rather than being kept in a separate nursery), not using a pacifier, and instructions on expressing breast milk. The logistic model showed that absence of these factors would lead to about 29% exclusive breast feeding at discharge. When all these factors were present the expected rate increased to over 82%. These four variables probably represent the effect of training; grouped together, they were significantly associated with exclusive breast feeding at discharge (odds ratio 6.78; 95% confidence interval 5.65 to 8.14). Other factors associated with the same outcome were normal delivery (1.49; 1.21 to 1.84) and previous experience of breast feeding (1.45; 1.21 to 1.74). Full breast feeding at three months was significantly associated with exclusive breast feeding at discharge (1.96; 1.63 to 2.36) and previous experience of breast feeding (1.58; 1.34 to 1.87); training health workers had a positive but not significant association (1.20; 1.00 to 1.44; P=0.0543). At six months any breast feeding was significantly associated only with full breast feeding at three months (12.83; 10.32 to 15.95) and with exclusive breast feeding at discharge (1.33; 1.07 to 1.65).

Lessons learnt and next steps

We found that training had an effect on hospital practices and breastfeeding rates, as has been reported previously from Belarus18 and the United Kingdom.25 Previous research looked only at hospital practices and at knowledge, attitudes, and practices of health workers 5 14-17 or at the effect of changing policies rather than training.26 Our study was not a randomised trial, but the design allowed for control before and after in each group of hospitals. We could also separate the effect of the intervention from the possible effect of uncontrolled variables—a secular trend or a chance improvement after training that does not persist in time. Standardisation took care of other differences. Moreover, data were collected on several outcomes. Confounding, some loss to follow up, and some incompleteness of data may compound the interpretation of the effect of training on single outcomes, but the consistent overall picture suggests that this effect is real.

The rates of exclusive breast feeding at three and six months are still not satisfactory, compared with what is recommended. 1 21 Also, we consider that rates obtained with 24 hour recall may overestimate the real rates that might be obtained with longitudinal follow up every date from birth.27 The falling rate of exclusive breast feeding after discharge may be due to a lack of adequate support: many paediatricians lack the necessary competence,9 and there are no other support groups except for some lactation and La Leche League consultants in some Italian towns. Extended networks of peer counsellors, whose effectiveness in supporting breast feeding has already been described,28-30 could integrate the skilled support and follow up provided by trained health professionals.31

To conclude, we recommend that effective training on breast feeding (over least three days, with practical sessions and emphasis on counselling skills) be included in all undergraduate courses leading to healthcare degrees and in all plans for in-service training in high income countries. For in-service training, it is important to target multidisciplinary groups of health workers involved in breast feeding at hospital and community levels. The implementation of effective interventions should not be limited to the healthcare system; it should cover a wider range of activities, aimed at changing the cultural representation of breast feeding32 and at defending breast feeding from the marketing of breast milk substitutes.33