Being involved in the change management required to achieve ‘Baby-Friendly’ practices highlights the fact that it is not an easy task and is somewhat challenging. However, once the standard is achieved there is a tremendous pride within the organisation and this contributes to a positive corporate culture. The Pennine Acute NHS Hospitals Trust, Blackburn, Derby, Bradford and Halifax hospitals are all good examples of the success of the BFHI. All of these hospitals serve populations with higher-than-average deprivation scores, and the deprivation in the northeast sector of Greater Manchester is clearly linked to the
increased minority ethnic populations, pockets of social deprivation and higher-than-average levels of adolescent pregnancy. In the northeast sector of Greater Manchester, the breastfeeding initiation rate is below the national standards (Table 7.2). However, the area’s organisational strategic aims show a commitment to improve the health of the local population and to reduce health inequalities by altering the culture.
One hospital in the northwest of England implemented the UNICEF BFHI standards and showed improved breastfeeding rates. In 1994, 29% of women began to breastfeed their babies but before they were discharged from the maternity unit almost all of them had stopped. The reasons given were sore nipples, frequent feeding, unsettled babies and too little or poor-quality milk. It was noted that all of the above could be addressed by an improvement in professional practice.
The journey began by identifying a leader who had a passion to support women to breastfeed successfully. Future prospects for the leader would involve managing a fundamental change in practice.
This task was daunting, but ‘anybody can change things, you make a difference if you feel it’s worthwhile and if you really care, it’s the belief that’s important’ (Palmer 2003). Whilst the challenge of becoming Baby Friendly can seem overwhelming, a belief in the philosophy underpinning the programme can enhance the potential for success.
Champions (i.e. staff members who were interested and passionate about breastfeeding) were crucial to the success of the programme. The team of champions was made familiar with the BFHI and each staff member was relied upon to influence and assist in directing the changes required within their individual working areas, giving them ownership of the change.
Step 1: A written breastfeeding policy
The programme expects a breastfeeding policy for staff and parents.
A multidisciplinary team formulated the breastfeeding policy and a consultative process followed in order for all medical, midwifery and nursing staff to agree to its contents and have ownership. A joint policy was designed for both acute and primary care settings. The policy was based on current evidence and was freely available for both mothers and staff, either as a written document or via the Trust’s intranet system.
Step 2: Staff education
The Ten Steps were used to formulate a staff-training programme for all levels of staff, from the ward cleaners to consultant staff, as anyone who came into contact with breastfeeding women and their babies required
some level of guidance. Dykes (2006) states that knowledge comes from a variety of sources: embodied knowledge (subjective, acquired through personal experiences and perceptions of breastfeeding a baby); vicar-ious knowledge (general learning generated throughout life, seeing others breastfeed); practice-based knowledge (learned by observation of others) and formal theoretical knowledge (structured learning oppor-tunities within education). Each aspect of learning must be addressed within the educational package for professionals if it is to be successful.
The 18-hour training requirement from UNICEF may be a stumbling block for many organisations, yet it is essential if breastfeeding practices are to improve. This challenge could be overcome by having a practical workshop that takes place over a 5-hour period, focused on developing and enhancing skills for breastfeeding and taught in an innovative and user-friendly way. Completing a workbook equates to a further 5 hours and provides the theory that underpins the practical session. Clinical supervision and ward-based reflective sessions meet the remaining 8 hours of the 18-hour programme.
Locally for the author, this training was made mandatory on an annual basis. Supervised practice was crucial, as some staff had never seen a woman or a baby breastfeed and were unaware of the different positions that could be used and why positioning and attachment were so important. The sessions empowered staff to consider all aspects of their care, and helped them to realise that the mother must be the ‘expert’
and that they needed to support her in an unobtrusive and gentle way.
A separate programme was designed and delivered to medical staff on a bi-annual basis and equates to 1 hour of study. In the past, there had been little or no education provided for medical staff, and to our surprise, most of them welcomed the sessions.
All training is monitored and evaluated on a database, with supervi-sors of midwives and managers being informed annually of attendance, as it is their responsibility to ensure staff compliance.
Step 3: Antenatal information
Antenatal workshops, breastfeeding sessions in parent-craft and ante-natal checklists of information given were developed. The curriculum for antenatal education includes the health benefits of breastfeeding, breastfeeding in hospitals, the benefits of having skin-to-skin contact at birth, rooming-in and baby-led feeding, coping with contradictory advice, support systems for successful and enjoyable breastfeeding and managing early challenges. The checklist and patient interviews enable an audit of this standard and the results are fed back on a frequent basis so that staff can see that they are achieving the standard or what needs to be improved.
Step 4: Skin-to-skin contact
The importance of keeping mothers and babies together is paramount, whether mothers choose to breastfeed or not. Midwives are aware of the evidence supporting the effects of skin-to-skin contact, for example, the thermo-regulation that occurs between mother and baby (Christensson et al. 1992) that skin contact stabilises the baby’s heart and respiratory rate (Lagercrantz & Slotkin 1986; Christensson et al. 1995) and that early breastfeeding takes place. The baby becomes colonised against bacteria from the mother’s home environment which are prevalent in her skin flora at the time of birth (Christensson et al. 1992). Midwives encourage mothers to keep their babies in close skin contact following birth for even longer periods than those recommended by UNICEF, particularly if the baby has not initiated breastfeeding within the first hour of birth.
Midwives recognise that their workload is likely to be more if a baby has not fed early and is separated from its mother.
Step 5: Show women how to breastfeed and maintain their lactation if separated from their babies
This step focuses on staff skills, to support the ability for them to use a hands-off-mother approach to teach new mothers how to breastfeed independently. Staff must also be skilled in hand expression and in teaching the mother this skill, so that she is self-reliant. If the baby has to be separated from its mother, the mother will be advised to hand-express or use a pump at least eight times in 24 hours, with one of those times being at night. Prolactin, the milk-producing hormone, is known to peak from midnight, so expression of milk after this time will increase the milk yield the following day (Riordan 2005). The mother is less likely to wake up with engorged breasts if she has expressed her milk during the night.
Step 6: Give breastfed babies no food or drink other than their mother’s breast milk
Staff may have a poor understanding of why this information is important, and implementation can be challenging. Educating staff and women through raising awareness of the effects of supplemen-tary feeds helps enormously. Supplemensupplemen-tary feeds affect the immature infant’s immune system and increase the risks of infection (Howie et al.
1990), which is so important in local populations where there is a high incidence of asthma, eczema and diabetes, and the literature demon-strates that this sensitivity to allergens has been traced to early and
complimentary artificial milk feeds (Pettitt et al. 1997; Minchin 1998;
Paronen et al. 2000). Apart from the obvious health risks, the effect on the mother’s lactation needs to be given recognition. The mother’s con-fidence in her milk production or even the quality of her milk may be undermined when supplements are offered. A baby that has received formula milk is less likely to be satisfied with the small volume of milk the breasts produce in the early days. If a mother does not feed her baby then her breasts may become overfull. Increase in a protein within the milk (feedback inhibitor of lactation) when breasts are left full for a period of time may diminish the mother’s lactation, and this can be either a short- or a long-term effect (Riordan 2005).
Step 7: Rooming-in
Rooming-in ensures confident mothering (Ekstr ¨om et al. 2005) as the mother learns to pick up and respond to her baby’s cues. Most staff were happy to see the withdrawal of the use of nurseries and the babies next to their mothers.
The use of clip-on-cots on the postnatal ward has assisted in the success of achieving this standard. The postnatal ward is not suitable for co-sleeping (Ball et al. 2006) and studies suggest that babies in clip-on-cots feed as frequently as those that do bed-share and co-sleep with their mothers (Ball et al. 2006). The Trust’s decision to provide the cots has shown their commitment to the Baby-Friendly status and also to breastfeeding. The mothers articulate that they like the cots as they can self-care and do not have to rely on staff members to pass their babies to them. They can respond to their babies’ early cues for feeding and feel better that their babies are not crying and keeping other mothers and babies awake.
Step 8: Demand feeding
Encouraging breastfeeding on demand is an accepted postnatal ward practice. The mothers and staff are made aware of the baby’s physi-ology and expected feeding pattern. The mother quickly becomes the connoisseur, responsive to her baby’s early signs for feeding. Health-care workers and mothers are frequently surprised to find out that the baby’s stomach capacity at birth is 9 ml in total and that during day 1 of motherhood the breasts produce approximately 7 ml of colostrum per feed (38 ml per first 24 hours of feeding), (Hartmann et al. 1995). It is somewhat perplexing when one considers that artificially fed babies are encouraged to drink as much as 20 or 30 ml of formula milk with a tougher curd at this same time. Such practice helps us to see the
link between artificial feeding and obesity, with bottle-fed babies being heavier and larger than their breastfed counterparts at 1 year of age (Riordan 2005; WHO 2007).
Step 9: Give no teats, dummies or pacifiers to breastfed babies
This step establishes that no teats or dummies should be given to breastfed babies. Changing culture is never an easy task and dummies have been used for many years, with, almost 80% of babies given one to pacify them (Howard et al. 2003). The use of dummies is more common in populations of lower socio-economic status (Mathur et al.
1990). What becomes clear is that if we are to meet the challenge of this step then mothers need to be made aware of other ways that they can settle their babies, for example, rocking, containment holding and skin-to-skin contact.
All interventions should have a solid rationale and research basis before becoming recommended practice by healthcare professionals.
Given that there is a lack of evidence of benefit and a wide and diverse documented risk associated with the use of dummies (Howard et al. 2003), parents should be cautioned to avoid them during early breastfeeding. The ‘social’ use of dummies has been linked to dental and orthodontic problems (Drane 1996) and to accidents such as choking, increased risks of thrush and other infections (Mattos-Graner et al.
2001). Lehtonen (1998) suggests that dummies can affect speech and developmental progress, and furthermore a baby that is sucking on a dummy will have limited periods of suckling at the breast and this may consequently affect milk drainage and thus limit milk production (Aarts et al. 1999).
Mothers who wish to use a dummy or teat in the early period should be informed that use in the first 4 weeks of life may affect breast milk production and potentially could cause breast refusal. During this time, both the mother and her baby are learning the art and skill of breastfeeding and it is important that nothing interferes with their learning. However, if a mother chooses to use a dummy she should be told not to withdraw it suddenly and to put the baby to sleep with a dummy at each occurrence in line with the recent guidance on risks of Sudden Infant Death Syndrome (Hauck et al. 2005).
Step 10: Establish support groups and refer mothers to them
Breastfeeding support groups, both volunteer and professional, should be available and mothers should be told about them while in hospital.
Women need to know where they can get help in order to continue to breastfeed when they meet challenges and for access to social support.