OUTLINE

1. Background
2. Ten Steps and BFHI: significance
3. Social value: Australia and Indonesia case study

I acknowledge the traditional owner of the land on which I live and work, the Ngunnawal people, and pay my respect to the elder past, present and emerging.

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 BACKGROUND

3
 Disclaimer: This slide is not promoting bottle-feeding by including a picture of a bottle, as some would have it.

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ACCEPTABLE MEDICAL REASON FOR USE OF
BREASTMILK SUBSTITUTE
Permenkes no 39 tahun 2013 pasal 8-12

World Health Organization & UNICEF. 2009. Acceptable medical reasons for use of breast-milk substitutes [Online]. Available:
http://apps.who.int/iris/bitstream/handle/10665/69938/WHO_FCH_CAH_09.01_eng.pdf;jsessionid=E6DDD0E74718D61F15D764CB84765C41?sequence=1
[Accessed].

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 • 595,379 childhood deaths (6-59 • Prevent 98,243 deaths • Global health system treatment costs of
months) from diarrhea and from breast and US$1.1 billion annually
pneumonia each year ovarian cancer as well • Economic losses of premature child and
• 974,956 cases of childhood as type 2 diabetes each women’s mortality are estimated to equal
obesity each year year US$53.7 billion in future lost earnings each
year
• Cognitive losses US$285.4 billion annually
• Total global economic losses are estimated
*Walters, D. D., Phan , L. T. H., & Mathisen, R. (2019). The cost of not breastfeeding: global results from a US$341.3 billion ~ 0.70% global gross national
new tool. Health Policy and Planning. doi:10.1093/heapol/czz050 income
*Walters, D., Horton, S., Siregar, A. Y., Pitriyan, P., Hajeebhoy, N., Mathisen, R., . . . Rudert, C. (2016). The
cost of not breastfeeding in Southeast Asia. Health Policy Plan, 31(8), 1107-1116. • Indonesia - US$118 million per annum
doi:10.1093/heapol/czw044

Pramono, et.al. for Kuliah Tamu Alumni FKM UA 2021

WHO RECOMMENDATION ON INFANT AND
YOUNG CHILD FEEDING
• Early initiation of breastfeeding immediately after birth for minimum 1
hour

• Breastfeeding exclusively from birth until 6 months of age

• Complementary feeding since 6 months of age

• Continue breastfeeding until 2 years of age and beyond

Pramono, et.al. for Kuliah Tamu Alumni FKM UA 2021

8 Pramono, et.al. for Kuliah Tamu Alumni FKM UA 2021
 Exclusive breastfeeding
rate global = 44%

https://data.unicef.org/topic/nutrition/breastfeeding/

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 TEN STEPS AND BFHI

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 POLL
1. Apa yang anda pikirkan saat mendengar kata 10 LMKM dan/atau
BFHI?

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 Pramono, A., Desborough, J. & Smith, J. 2019. The Ten Steps
1989 2018 to Successful Breastfeeding Policy Review. Breastfeeding
Review, 27, 14.

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 BABY FRIENDLY HOSPITAL INITIATIVE
(BFHI)

• Launched in 1991

• To encourage maternity facility to implement Ten Steps

• Externally assessed every 3 years – to be baby-friendly accredited

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 POLL
1. Berapa lama durasi IMD yang pernah anda ketahui di RS?
2. Apa yang dimaksud dengan Rawat Gabung?

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 Bayi mulai merayap mencari payudara ibu
1. Pijakan kaki bayi diatas rahim ibu  (a) mempercepat
pengeluaran plasenta, (b) menghindari risiko
pendarahan
2. Gesekan kulit bayi & ibu  bakteri baik melindungi
kulit bayi
3. Hentakan kepala bayi pada payudara ibu = massage
payudara
4. Bayi menjilati kulit ibu  bakteri baik
5. Bayi meremas puting ibu  ‘mengeluarkan’ puting,
merangsang oksitosin

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 RAWAT GABUNG
Manfaat:

• Kontak kulit ibu dan bayi bisa lebih sering

dilakukan

• Ibu belajar mengenali tanda haus/lapar

sebelum bayi menangis

• Ibu lebih responsif, kegiatan menyusui lebih

lancar (oksitosin)

• Cara terbaik bagi ibu untuk dapat beristirahat

bayi selalu dalam jangkauan ibu 24 jam selama sambil menyusui
perawatan di rumah sakit
• Bayi tidak turun imunitas tubuhnya

• Meningkatkan kesuksesan menyusui

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 POLL
1. Apakah anda pernah mendengar tentang Kode Internasional
Pemasaran Produk Pengganti ASI?

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https://www.who.int/publications/i/item/9789240005990

Pramono, et.al. for Kuliah Tamu Alumni FKM UA 2021

Why BFHI/Ten Steps important?
• Babies born in a hospital with the UK BFHI standard award were 28% (p <
0.001) more likely to be exclusively breastfed at 7 days postnatally than those
born in non-BFHI hospitals*
• Infants born in baby-friendly hospitals were more likely to be breastfed for
longer than those born in non-baby-friendly facilities*
• infants from sites receiving experimental intervention of the BFHI model were
seven times more likely to be exclusively breastfed at 4 months and had
significantly reduced risks of gastrointestinal tract infection and atopic eczema
than control infants*** This Photo by Unknown Author is licensed
under CC BY

*Broadfoot M, Britten J, Tappin DM, MacKenzie JM. The Baby Friendly Hospital Initiative and breast feeding rates in Scotland. Arch Dis Child Fetal Neonatal Ed.
2005;90(2):F114-6
**Merten S, Dratva J, Ackermann-Liebrich U. Do baby-friendly hospitals influence breastfeeding duration on a national level? Pediatrics. 2005;116(5):e702-8.
*** Kramer MS, Chalmers B, Hodnett ED, et al. Promotion of breastfeeding intervention trial (probit): A randomized trial in the republic of belarus. JAMA.
2001;285(4):413-20.

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 Global – 10% babies born in Baby-
friendly hospital

Australia – 26% Baby-friendly

accredited

Indonesia – 8% of government
hospitals categorized as implementing
Ten Steps

Green: >=50% of births in hospitals and maternity designated

as Baby-Friendly
Yellow: 20-50% of births *BFHI Australia. (2020). About BFHI. Retrieved 19 December 2020 from
Orange: 0.1-20% of births https://bfhi.org.au/about/
Red: No births ** Agency of Health Research and Development 2011. Riset Fasilitas
Grey: no data Kesehatan (Health Facilities Research).

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 Social value of
Ten Steps and BFHI

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SOCIAL RETURN ON INVESTMENT (SROI)

1. Establishing scope and involving stakeholders

2. Mapping outcomes
3. Evidencing and valuing outcomes
4. Establishing Impact
5. Calculating the SROI and sensitivity analysis

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 Australian case study

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 BFHI in Australia
• BFHI status is awarded to hospitals that implement consistent
high quality and ethical maternity care through the Ten Steps to
Successful Breastfeeding policy; while remaining independent
from formula companies and their affiliates, and is re-assessed
every three years.

• UNICEF Australia passed governance of BFHI within Australia to

Australian College of Midwives.

• In 2006, the Australian Baby Friendly Hospital Initiative became

the Baby Friendly Health Initiative in order to more accurately
reflect the expansion of the initiative into community health
facilities.
World Health Organization. Baby Friendly Hospital Initiative 2018 [Available from: http://www.who.int/nutrition/topics/bfhi/en/.
Australian College of Midwives. Baby Friendly Health Initiative (BFHI) Accreditation 2018 [Available from: https://www.midwives.org.au/baby-friendly-health-initiative-bfhi-accreditation.

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 Based on 1989 Ten Steps Based on 2018 Ten Steps

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 Findings

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 every AU$ 1 invested in maintaining BFHI accreditation in this hospital
generated approximately AU$ 55 of benefit.
*sensitivity analysis: AU$ 16-112

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 Indonesian case study

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Breastfeeding regulation
PP no 33 tahun 2012 tentang ASI Eksklusif

Permenkes no 39 tahun 2013 tentang Susu Formula Bayi dan Produk Bayi Lainnya

Permenkes no 15 tahun 2014 tentang Tata Cara Pengenaan Sanksi Administratif bagi tenaga
Kesehatan, penyelenggara fasyankes, penyelenggara satuan Pendidikan Kesehatan, pengurus
organisasi profesi di bid Kesehatan, serta produsen dan distributor sufor bayi dan/atau produk bayi
lainnya yang dapat menghambat keberhasilan program pemberian ASI eksklusif

Permenkes no 15 tahun 2013 tentang Prosedur Penyediaan Ruang Menyusui dan/atau Memerah ASI

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Ten Steps in Indonesia

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 Findings

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 every US$ 1 invested in implementing Ten Steps in this hospital generated
approximately US$ 49 of benefit.
*sensitivity analysis: US$ 18-65

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 CONCLUSION
• Breastfeeding has the potential to help address inequity throughout the lifetime by providing the
equal best start to all infants regardless of their background

• Providing the highest standard of care for breastfeeding through Ten Steps implementation and
BFHI accreditation is essential for health equity

• Indonesia’s initial moves towards implementing the Ten Steps can be strengthened by
integrating all elements into the health care system

• Scaled up nationally, the BFHI could provide important benefits to the Australian health system
and national economy.

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THANK YOU
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Andini Pramono

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Email: Andini.Pramono@anu.edu.au
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