International Board

Certified Lactation
Consultant 2009
Dokter Spesialis Anak
FKUI 2006
Dokter Umum FKUI
2000

Dosen FK UPH
Mitra Peneliti Pusat
Penelitian Kesehatan UI
RSUK Pesanggrahan
Pengurus Sentra Laktasi
Indonesia

Dr. Fransisca Handy, SpA

Hospital Care for Breastfeeding Support

in Indonesia through
Baby Friendly Hospital Initiative

Study 1

Background

Breastfeeding is an effective preventive health measures

to reduce infant morbidity and mortality and promote
maternal health

To improve worldwide breastfeeding initiation and duration

rates, in 1991, WHO and UNICEF launched the Baby-Friendly
Hospital Initiative (BHFI) : 10 Steps to Successful
Breastfeeding & International Code of Marketing of BMS

Factors Affecting Sucessfull Breastfeeding

Policy
Institutional
Hospital
breastfeeding support
Interpersonal
Family, peers
Physician
Workplace
Individual
Knowledge
Attitudes
belief
Bronfenbrenner. The Ecology of Human Development: experiments by nature and Design . Harvard University Press, 1979

BFHI is the gold standard for

evidence-based breastfeeding care in the hospitals

BFHI is a strategy to improve the practice of health

professionals within hospital setting

BFHI improves the care both for sick and healthy newborn

For sick newborn: breastfeeding is life saving, thus it reduces

IMR directly

Adherence to 10 Steps predicts

breastfeeding duration long after discharge

Philipp BL, et al. Arch Dis Child Fetal Neonatal Ed 2006;91:F145-149

Abraham SW, Labbock MH. Interrnational Breastfeeding Journal 2009

10 Steps of Sucessfull Breastfeeding

5

1
Hospital staff

10

National health system should protect and promote

breastfeeding and implement the code

Country need to improve health workerss

capacity on breastfeeding

Health facility can not be the place for BMS promotion

Health facility can not provide cheap nor free BMS

No BMS bussiness in the health service system

Health workers know how to prescribe BMS as
medically indicated

5 BFHI modules
National Program
Guideline
Hospital Managers
Course
Self
Appraisal
Section

External
Assessment
Section

Clinical Staff
Course

BFHI, 1991
2011 : 21.328 health facilities
in 131 countries designated Baby Friendly
Malaysia 2012:
Australia 2010:
- all 139 state hospitals,
77 hospitals (20%)
- all 4 teaching hospitals,
UK 2013
Indonesia
? :62 facilities (78%)
- 2/3 armed forced hospitals,
USA 2014: 286 facilities (5%)
- 8/200 private hospitals
Austria 2013: 16% facilities
Singapore 2013: 5/25 hospitals
Thailand 2007: 53% hospitals

Labbok MH. Global BFHI monitoring data: update and discussion. Breastfeeding Medicine, 2012
Baby Friendly Hospital Initiative. http://www.bfhi.orh.au
www.ongkg.at/baby-friendly/bfh-in-oesterreich.html

10 Steps in Indonesia
5

10

Health Facility Survey 2011:

8% District Hospital implemented 7 out of 10 steps

Based on the above situation,

2 studies need to be carried out :
1.

A study to assess why BFHI is still poorly implemented at

policy and practical level

2.

A pilot project to implement BFHI in Indonesia to provide

local evidences on its impact on breastfeeding rate and
evidences on how we could do best to implement it

Aim of Study
Study #1

To review the BFHI implementation in Indonesia

To identify the obstacles and opportunities of hospital support
for breastfeeding

Study #2

To have Indonesia s model for improving hospital support for

breastfeeding
To provide local evidence of the effect of BFHI
To compare the effect of BFHI training on breastfeeding
rates for sick babies and for well babies

Study 1
Methodology

A Qualitative Study

In-depth interviews
Documents review

Policy
MoH

Professional Org

Institutional
Hospital
breastfeeding support

PHO

Managers
DHO

Interpersonal

Mother
Support
Group

Individual
Exit client

Midwive
Nurse
Obgyn
Clinical
Ped
Staff

Father
Support
Group

Field Set
up

Qualitative
Guideline
development

Field
Testing

Study 1 Preparation

Interviewer
Training

Participating Hospitals
Hospital Type

Banten

Jakarta

West Java

State owned
Type A

State Teaching
Hospital

Type B
Type C

District hospital
District hospital

Type D

Sub district
hospital

Private owned
General
Maternal &
Child

Private Teaching
Hospital
New private
hospital

Covering all type of hospitals

Old private
hospital
City owned

Themes

In-depth interviews
Documents review

Policy
Regulation

Recommendation
Institutional
Hospital
SOP
breastfeeding support

Pre &In
Service
Training

10 Steps

Knowledge
Skill
Practice

Interpersonal

WHO
Code
Back
ground

Community
Support
Group

Activity

Individual
Mothers demand
& experience

Monev & Coordination

Step 10

Result

Government National Policy

Provincial / District Policy

DHO officer 1 : Policy on breastfeeding support and WHO code is not (yet) available
(We) refer on goverment rule No. 33 2012.
PHO officer 2 : At provincial level there is no (written) local regulation (PERDA)
PHO officer 3 : There is no breastfeeding support policy launched
by provincial goverment. So far we use Central Level goverment and
ministrial decree

Facilitators
National regulations
are in place
Socialization is
happening
Recognition /
acknowledgement is
done

{Barriers
No monitoring and
evaluation process
No sanctions to those
who are not
implementing

National Policy - Goverment

National Policy (Professional Org)

Midwive

Nurse

Nutritionist

Recommenda
tion

Refer to
national policy

Refer to
national policy

Involved in
None written
national policy recommendati
on

On special
events

Program

Bidan Delima
(general)

n/a

n/a

n/a

First 1000 days

SOP

Refer to
national policy

n/a

Refer to IYCF
and BF
counsellor
module

Involved in
national SOP
development:
antenatal
education,
early contact
of BF

Early contact
of BF,
common
problems in
newborn, not
yet for BF
problems

Sosialization

bulletin, web
site, meetings

Only to board
of organization

Website,
meetings

Website,
books

Monev

n/a

n/a

n/a

n/a

n/a

OBGYN

Pediatrician

National Policy (Professional Org)

Midwive
Pre service
training
curriculla

National level
IBI involved

In service
training

Available in
collaboration
with other
parties

Nurse
Unclear jobdes for
maternity
nurse

Nutritionist

OBGYN

Pediatrician

Available, no
coordination
with other
profession

Physiology of
BF and early
initiation for
med student

On progress,
improvement
needed

BF counselling
trainings

Scientific
meetings

Scientific
meetings

10 Steps Written Policy

Hospital Policy on Not giving bottle and teats

Truncated displayed 10 steps

Beautiful 10 steps display

from pharmaceutical industry

Hospital Policy Step 1

Clinical
Protocols
Antenatal Protocol
Early Initiation of Breastfeeding Protocol

1 hour?
Rooming in Protocol

SOP Hypoglicemia

No-mentioned
breastmilk

SOP Hyperbilirubinemia

No hospital has
written BMS
medical indication

Breast milk /
breastfeeding
has not yet
mentioned in the
SOP for sick
newborn

SOP for sick newborn

Facilitators
Most hospital have
written policies (on 10
steps)
Some SOPs are
available (early
initiation, rooming in)

{Barriers
Socialization
Some protocols for
routine procedure are
not adequate
Clinical guideline on
breastfeeding
problems
Medical indication for
breastmilk subtitute

Hospital Policy Step 1

Some has formula

advertising
Some staff in some
hospital said Yes, but
not with a written MoU
1 hospital: routine
formula preparation
from nutrition unit

WHO Code Implementation

All hospital stated no collaboration with fomula industry

Training Step 2
Staff Education is the central component of BFHI program.
Only with trained staff can the necessary practice changes be made
Arch Dis Child Fetal Neonatal Ed 2006;91:F145-9

Most hospital has no BFHI training experience

Few hospital has in house trainings, yet these are more for the
midwives and nurses, none for doctors and some are un-structured
(non class training, only bed-side).
Some hospitals have breastfeeding counsellors or trained staff in
breasfeeding but too few in numbers and mostly has many other
tasks to do

Pre Service

In Service

Pediatrician A

Nothing in detail

I have never participate (in

any breastfeeding course)

Obgyn B

We learnt (about
breastfeeding) by our
selves

In 2004. Lactation
management

Midwife D

Yes, for positioning and

2 days-(un-structured) on
attachment. Nothing else the job training (at the
hospital)

Nurse E

in the maternity
education there was
breastfeeding (topic) but
only at a glance

Yes, 5 days breastfeeding

counselor training

Starting points Step 3,4

Antenatal Education on Breastfeeding
Only informant from MoH mentioned about the antenatal information
contained in Maternal and Child handbook (Buku KIA) and the Mother
Class Program (Kelas Ibu). None ot the hospital staff aware of the existance
of this information.
Some hospital has antenatal class for pregnant exercise, breastfeeding issue
inserted in this class
One hospital has a more structured ante natal class. Yet, the given
information is lacking on breastfeeding benefit (formula disadvatages), early
initiation on breastfeeding, rooming in and breastfeeding in early days.
Thus, many mothers are unsuccessfull.
and a lack of continuity of care in the antenatal period, making their efforts feel
useless in hospital setting.
Chabot et al. Factors influencing the intention of perinatal nurse to adopt BFHI in Canada.
Nursing research and practice 2014

Starting points Step 3,4

Early Initiation of Breastfeeding (IMD) is a popular issue.

- Mentioned in all written policy
- The term IMD dan exclusive breastfeeding mentioned oftenly compare to 10 steps or BFHI

Some hospitals have a good detail clinical protocol of early initiation of

breastfeeding
None of the hospital implement true 1 hour skin to skin contact for all
eligible mother & infant
1.
2.
3.

Major constrains: time & number of staff

Cold temperature (for SC) and mothers willingness.
Obgyn reluctance .

...midwives need to stay in the theatre for a while. In the past we could return directly
and fulfill other tasks.
Especially among gynecologists.. There were some who refused it (BFHI)
Wieczorek et al. BFHI qualitative study, Austria Int Breastfeeding Journal 2015; 10:3

{Barriers

Most participants know basic

breastfeeding benefit
All participants basically
support breastfeeding
All hospital implemented
rooming-in (partially)
None of the hospital has
feeding schedule

Facilitators

Poor counseling skill for

breastfeeding support in early
days
Lack of time and staff resources
Old patterns
Poor expressed breast milk
management, including cup
feeding
Lack of support for sick
newborn esp in referral
hospitals

Clinical Supports Step 5,6,7,8,9

Clinical Supports facilitators

Participants in this study were committed to the principles of BFHI, believed it was
achievable and were mostly keen to gain BFHI accreditation
Schimed V, et al. Australian health professionals perception. BMC Health Service Research 2011

Facilitators of BFHI operation: skill of the staff, management support &

commitment
In each hospital, change agent were identified, who promoted the BFHI, teamed up
with the managers of other professional groups and finally with the manager of unit.
Wieczorek et al. BFHI qualitative study, Austria Int Breastfeeding Journal 2015

Respondent who believed in their capacity to overcome barriers had strong intention to
adopt it
Nurse can play a major role in preventing in-hospital supplementation that can impede
the lactation process

Chabot et al. Factors influencing the intention of perinatal nurse to adopt BFHI in Canada.
Nursing research and practice 2014

Clinical Supports barriers

Some practices such taking a baby into the nursery for 2 or 3 hours at night were
rationalized as supporting a desperately tired mothers
The pressure of time may lead some health professionals to take short cuts or seek a
quick fix (giving formula)
I think, like every human being, we fight change because we get in out comfort
zone
Schimed V, et al. Australian health professionals perception. BMC Health Service Research 2011

Several participants felt that working according to BFHI standards needed more time in
particular situations.
Many participants saw persisting in old patterns as a major factor leading to resistance
against the required changes
Wieczorek et al. BFHI qualitative study, Austria Int Breastfeeding Journal 2015

Sick babies reduce the likelihood that breastfeeding will be established or exclusive
Moore T, et al. Implementing BFHI policy: the case of New Zealand public Hospitals. Int Breastfeeding
Journal 2007

After discharged Step 10

Australia: 90% women initiating breastfeeding, however
exclusive breastfeeding rates drops rapidly following discharge.
Austria: 93,2 moterhs initiate breastfeeding, yet
it dropped to 9.7% by 6 months

Only 1 hospital has official mother support group, yet not

all staff knew it
Community supports are in place. They are active and very
committed, yet inadequate resources (esp human) and
very few coordination with health facilities

Summary

Facilitators

National and hospital

policies are in place
Awarness on the
importance of
breastfeeding
Community support is
available and active

{Barriers

Knowledge and skill of the

hospital staff
Lack of clinical guidelines
on BF problems
Lack of time and staff
resources
Old patterns
Weak coordination among
stake holders

BFHI Implementation in Indonesia

BFHI is achievable,
it just need commitement and hard work

lets make it work!

Thank You!