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

2

7

1
Hospital staff

3

6

4

8

9

10

National health system should protect and promote
breastfeeding and implement the code

Country need to improve health workers’s
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

4

6

7

8

1

9

3

10

5

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
Mother’s 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 mother’s 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

let’s make it work!

Thank You!

{