Kajian Kualitatif Dukungan Menyusui Di RS Melalui Program RS Sayang Bayi Di Indonesia

7/23/2019 Kajian Kualitatif Dukungan Menyusui Di RS Melalui Program RS Sayang Bayi Di Indonesia

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Dr. Fransisca Handy, SpA

International Board

Certified LactationConsultant 2009

Dokter Spesialis Anak

FKUI 2006

Dokter Umum FKUI2000

Dosen FK UPH Mitra Peneliti Pusat

Penelitian Kesehatan UI

RSUK Pesanggrahan

Pengurus Sentra Laktasi

Indonesia


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{

Hospital Care for Breastfeeding Supportin Indonesia through

Baby Friendly Hospital Initiative

Study 1


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{

Background


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Breastfeeding is an effective preventive health measures

to reduce infant morbidity and mortality and promotematernal health

To improve worldwide breastfeeding initiation and durationrates, in 1991, WHO and UNICEF launched the Baby-FriendlyHospital Initiative(BHFI) : 10 Steps to SuccessfulBreastfeeding & International Code of Marketing of BMS


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Factors Affecting Sucessfull Breastfeeding

Policy

InstitutionalHospital

breastfeeding support

InterpersonalFamily, peers

PhysicianWorkplace

IndividualKnowledge

Attitudesbelief

Bronfenbrenner. The Ecology of Human Development: experiments by nature and Design . Harvard University Press, 1979


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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:F145-149Abraham SW, Labbock MH. Interrnational Breastfeeding Journal 2009


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1

2

3

4

5

9

7

68

10

10 Steps of Sucessfull Breastfeeding

Hospital staff


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National health system should protect and promotebreastfeeding and implement the code

Country need to improve health workersscapacity 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


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5 BFHI modules

National ProgramGuideline

Hospital Managers

Course

Clinical StaffCourse

Self AppraisalSection

ExternalAssessment

Section


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BFHI, 19912011 : 21.328 health facilities

in 131 countries designated Baby Friendly

Malaysia 2012:

- all 139 state hospitals,- all 4 teaching hospitals,

- 2/3 armed forced hospitals,

- 8/200 private hospitals

Singapore 2013: 5/25 hospitals

Thailand 2007: 53% hospitals

Australia 2010:

77 hospitals (20%) UK 2013 :62 facilities (78%)

USA 2014: 286 facilities (5%)

Austria 2013: 16% facilities

Labbok MH. Global BFHI monitoring data: update and discussion. Breastfeeding Medicine, 2012Baby Friendly Hospital Initiative. http://www.bfhi.orh.au

www.ongkg.at/baby-friendly/bfh-in-oesterreich.html

Indonesia ?
http://www.bfhi.orh.au/http://www.ongkg.at/baby-friendly/bfh-in-oesterreich.htmlhttp://www.ongkg.at/baby-friendly/bfh-in-oesterreich.htmlhttp://www.ongkg.at/baby-friendly/bfh-in-oesterreich.htmlhttp://www.ongkg.at/baby-friendly/bfh-in-oesterreich.htmlhttp://www.ongkg.at/baby-friendly/bfh-in-oesterreich.htmlhttp://www.ongkg.at/baby-friendly/bfh-in-oesterreich.htmlhttp://www.ongkg.at/baby-friendly/bfh-in-oesterreich.htmlhttp://www.ongkg.at/baby-friendly/bfh-in-oesterreich.htmlhttp://www.bfhi.orh.au/


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10 Steps in Indonesia

Health Facility Survey 2011:

8% District Hospital implemented 7 out of 10 steps

1

3

5 6 7

8

9

10

5

4


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Based on the above situation,2 studies need to be carried out :

1. A study to assess why BFHI is still poorly implemented atpolicy and practical level

2. A pilot project to implement BFHI in Indonesia to providelocal evidences on its impact on breastfeeding rate and

evidences on how we could do best to implement it


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Study #1 To review the BFHI implementation in Indonesia

To identify the obstacles and opportunities of hospital supportfor breastfeeding

Study #2

To have Indonesia s modelfor improving hospital support forbreastfeeding

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

Aim of Study


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{

Study 1

Methodology


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Policy



Interpersonal

Individual

A Qualitative Study

MoH

DHO

PHO

Professional Org

Ped

Obgyn

Midwive

Nurse

Managers Clinical

Staff

Mother

SupportGroup

Father

SupportGroup

In-depth interviewsDocuments review

Exit client


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Study 1 Preparation

Field Set

up

Qualitative

Guidelinedevelopment

Field

Testing

Interviewer

Training


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Participating Hospitals

Hospital Type Banten Jakarta West JavaState owned

Type A State TeachingHospital

Type B District hospital

Type C District hospital

Type D Sub districthospital

Private owned

General Private TeachingHospital

Old privatehospital

Maternal &Child

New privatehospital

City owned

Covering all type of hospitals


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Policy



Interpersonal

IndividualMothers demand

& experience

Community

Support

Group

In-depth interviewsDocuments review

Themes

Regulation

SOP

Monev & Coordination

Pre &InService

Training

Recommendation

WHOCode

10 Steps KnowledgeSkill

Practice

Background

Activity

Step 10


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{

Result


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Government National 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 andministrial decree

Provincial / District Policy


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{ {

National Policy - Goverment

Facilitators

National regulationsare in place

Socialization ishappening

Recognition /acknowledgement isdone

Barriers

No monitoring andevaluation process

No sanctions to those

who are notimplementing


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National Policy (Professional Org)

Midwive Nurse Nutritionist OBGYN Pediatrician

Recommenda

tion

Refer to

national policy

Refer to

national policy

Involved in

national policy

None written

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 contactof BF

Early contact

of BF,

common

problems in

newborn, not

yet for BFproblems

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


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National Policy (Professional Org)

Midwive Nurse Nutritionist OBGYN Pediatrician

Pre service

training

curriculla

National level

IBI involved

Unclear job-

des for

maternity

nurse

Available, no

coordination

with other

profession

Physiology of

BF and early

initiation for

med student

On progress,

improvement

needed

In servicetraining

Available incollaboration

with other

parties

BF counsellingtrainings

Scientificmeetings

Scientificmeetings


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Truncated displayed 10 steps

Hospital Policy on Not giving bottle and teats

10 Steps Written Policy

Beautiful 10 steps displayfrom pharmaceutical industry

Hospital Policy Step 1


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Rooming in Protocol

Antenatal Protocol

Early Initiation of Breastfeeding Protocol

1 hour?

Clinical

Protocols


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SOP Hypoglicemia

SOP for sick newborn

SOP Hyperbilirubinemia

No-mentionedbreastmilk

No hospital haswritten BMS

medical indication

Breast milk /breastfeeding

has not yet

mentioned in theSOP for sick

newborn


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{ {

Hospital Policy Step 1

Facilitators

Most hospital havewritten policies (on 10steps)

Some SOPs areavailable (earlyinitiation, rooming in)

Barriers

Socialization

Some protocols forroutine procedure arenot adequate

Clinical guideline onbreastfeedingproblems

Medical indication for

breastmilk subtitute


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WHO Code Implementation

All hospital stated no collaboration with fomula industry

Some has formulaadvertising

Some staff in some

hospital said Yes, but

not with a written MoU 1 hospital: routine

formula preparation

from nutrition unit


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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

Training Step 2

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 inbreasfeeding but too few in numbers and mostly has many othertasks to do


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Pre Service In Service

Pediatrician A Nothing in detail I have never participate (inany breastfeeding course)

Obgyn B We learnt (aboutbreastfeeding) by our

selves

In 2004. Lactationmanagement

Midwife D Yes, for positioningandattachment. Nothing else

2 days-(un-structured) onthe job training (at thehospital)

Nurse E in the maternity

education there wasbreastfeeding (topic) butonly at a glance

Yes,5 days breastfeeding

counselor training


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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 MotherClass Program (Kelas Ibu). None ot the hospital staff aware of the existanceof this information.

Some hospital has antenatal class for pregnant exercise, breastfeeding issueinserted in this class

One hospital has a more structured ante natal class. Yet, the giveninformation is lacking on breastfeeding benefit (formula disadvatages), earlyinitiation 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 feeluseless in hospital setting.

Chabot et al. Factors influencing the intention of perinatal nurse to adopt BFHI in Canada.

Nursing research and practice 2014


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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 ofbreastfeeding

Starting points Step 3,4

None of the hospital implement true 1 hour skin to skin contact for alleligible mother & infant

1. Major constrains: time & number of staff2. Cold temperature (for SC) and mothers willingness.3. Obgyn reluctance .

...midwives need to stay in the theatre for a while. In the past we could return directlyand 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


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{ {Facilitators

Most participants know basic

breastfeeding benefit

All participants basically

support breastfeeding All hospital implemented

rooming-in (partially)

None of the hospital has

feeding schedule

Barriers

Poor counseling skill forbreastfeeding support in earlydays

Lack of time and staff resources

Old patterns Poor expressed breast milk

management, including cupfeeding

Lack of support for sick

newborn esp in referralhospitals

Clinical SupportsStep 5,6,7,8,9


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Clinical Supportsfacilitators

Facilitatorsof 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

Participants in this study were committedto the principles of BFHI, believed it wasachievable and were mostly keen to gain BFHI accreditation

Schimed V, et al. Australian health professionals perception. BMC Health Service Research 2011

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

the lactation processChabot et al. Factors influencing the intention of perinatal nurse to adopt BFHI in Canada.

Nursing research and practice 2014


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Clinical Supportsbarriers

Several participants felt that working according to BFHI standards needed more time inparticular situations.

Many participants saw persisting in old patterns as a major factor leading to resistance

against the required changesWieczorek et al. BFHI qualitative study, Austria Int Breastfeeding Journal 2015

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 comfortzone

Schimed V, et al. Australian health professionals perception. BMC Health Service Research 2011

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 BreastfeedingJournal 2007


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After dischargedStep 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 notall staff knew it

Community supports are in place. They are active and verycommitted, yet inadequate resources (esp human) and

very few coordination with health facilities


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{

Summary


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{ {Facilitators

National and hospitalpolicies are in place

Awarness on theimportance 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 staffresources

Old patterns

Weak coordination among

stake holders

BFHI Implementation in Indonesia


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BFHI is achievable,it just need commitement and hard work

lets make it work!


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{

Thank You!

Kajian Kualitatif Dukungan Menyusui Di RS Melalui Program RS Sayang Bayi Di Indonesia

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