Ginny, congratulations to you and your colleagues in your hospital on
beginning the journey towards becoming baby-friendly.
I don't have any experience of BFHI in industrialized countries, but
was a BFHI assessor in Zimbabwe until 2003, when we used the figure
of 80% as the cut-off point to assess all the BFHI criteria. That
is, 80% of all randomly sampled nursing staff, and mothers had to
confirm that each one of the Ten Steps were being followed before the
hospital would receive the Baby Friendly award. Yes, any formula use
would need to be shown to be medically indicated, and true medical
indications are very few. So any reasons for formula supplementation
would have been checked out thoroughly (via the mother, the nursing
staff and written medical records and invoicing records) to see what
justification there was, and who paid for it - if it was the
hospital, did they purchase it and if so, did they pay at least 80%
of the normal retail price for it? Then, any separation of mom and
baby lasting longer than an hour would be similarly checked and
ascertained by asking the mother, then the nurse on duty at the time,
and looking at the medical indication for the separation. So if it
was found that two babies out of ten were removed from the mother to
the nursery (only at night?) and fed formula, even if at the mother's
request (did the mothers know why this shouldn't happen - had they
been told, and if so, who by - had that staff member been
trained?) then the hospital would fail.
The beautiful thing about the way the BFHI works is that it starts
right at the beginning and follows through until the end, and each of
the Ten Steps (the BFHI criteria) are checked in many different
ways. The really inspired mechanism, to my mind, is that it is
mothers, and not nursing staff, who pass or fail a hospital, since
more than twice as many mothers are interviewed than hospital staff,
and they will only have walked through the door in the last 0-48
hours or so, so they can't have been primed to give the right answers
to all the questions unless they've actually been through the whole
baby-friendly process. The assessment expects to find that at least
80% of mothers are to have received antenatal instruction on the
reasons for rooming in and exclusive breastfeeding, even before they
set foot in the hospital. Likewise at least 80% of the staff having
any contact with mothers and babies are to have been through the 18
hours of breastfeeding training - that's all staff, from the
receptionists, to the cleaners, to the midwives and
matrons. Mothers have to be able to show the assessors that they
know why breastfeeding is being promoted, how to breastfeed and how
to express their milk in case they should be separated from their
babies (ie assessors don't just take the word of staff that these
things have been taught, we want a visual demonstration _by the
mother_ and we may want a visual demo of say hand-expression by the
lab staff if they have been picked up in the random sampling.) Each
of the criteria is "tested" in several different ways, looking at
several different sources, so when it's done properly, the BFHI
assessment is impossible to fudge. Finally, each mother who enters
the hospital, knowing the reasons why breastfeeding is baby-friendly,
and is helped to practise exclusive breastfeeding from within the
first hour of birth, is finally discharged to a support group in the
community for on-going help.
I have the impression that maybe some of the criteria, eg the 80%
figure, have been watered down to 75% for industrialized
countries. And I suspect that maternal choice may be a reason for
certain mothers to be excluded from assessments, but I'm not sure and
maybe someone else can confirm. Meanwhile, I found a document called
Baby Friendly USA, Ten Steps to Successful breastfeeding, see
<http://www.babyfriendlyusa.org/eng/docs/BFUSAreport.pdf>http://www.babyfriendlyusa.org/eng/docs/BFUSAreport.pdf
which looks quite helpful. Pages 16-18 talk about 24 hour rooming in
and exclusive breastfeeding. I think you put your finger on the
"problem" Ginny by identifying the "education gap" that exists for
the mothers in your community. Your hospital is inheriting a
cultural expectation that new mothers need their sleep more than
their babies need their mothers and their milk! Perhaps the _first_
thing to do would be to invite antenatal teachers in your area to
talk about the value of the Ten Steps, and see if they couldn't be
persuaded to stress the value of 24-hour mother-baby togetherness and
breastfeeding as the only way forward because you're going to close
your well-baby nursery! Alternatively, your hospital could set up
its own antenatal classes, to let mothers know what to expect and why
exclusive breastfeeding is so good for their newborns. You'd need to
get your doctors and paediatricians on board too, and this might be
quite hard ....?
Good luck! I take my hat off to all of you in the
industrialised-country trenches working so hard to protect, promote
and support breastfeeding in what sometimes seems to me a very
hostile infant feeding environment!
Pamela Morrison IBCLC
Rustington, England
-------------------------
I work at an urban hospital with about 4000 deliveries a year. We
know we have a significant problem with supplementing BF infants with
formula for a variety of inappropriate reasons and want to begin the
process of decreasing this number and change the whole culture of
supplementing.
In other hospitals that are Baby Friendly or are heading that way-
how do they handle supplements when EBM or donor milk is not
available? What is the criteria for supplementing? Is an MD order obtained?
I see such a problem with parents who do not keep the infants in the
room past 10:00 at night, the nursery fills with screaming hungry
infants and the mothers tell the nurses that they are too tired to
feed the baby and to please give "JUST ONE BOTTLE" which is maddening
to say the least!!!
We have a huge education gap regarding normal breastfeeding patterns
and mothers who have never been around BF in a cultural context and
feel that sending the infant to the nursery is the norm- despite the
research- despite many nurses educating them to keep the infant in
the room to observe for cues etc.
Does any one know the average % of infants supplementing at BF
friendly hospitals and what those reasons are?
Any wisdom from any hospitals who have tackled this challenging
problem is much appreciated.
Thank you so much,
Ginny Combs RN, BSN, IBCLC
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