How midwives and nurses experience implementing ten steps to successful breastfeeding: a qualitative case study in an Indonesian maternity care facility.

BACKGROUND: The in-hospital stay following childbirth is a critical time for education and support of new mothers to establish breastfeeding. The WHO/UNICEF 'Ten Steps to Successful Breastfeeding (Ten Steps)' was launched globally in 1989 to encourage maternity services to educate and support mothers to breastfeed. The strategy is effective, however its uptake within health systems and facilities has been disappointing. We aimed to understand midwives' and nurses' experiences of implementing the Ten Steps in an Indonesian hospital. METHODS: This qualitative study was conducted in an Indonesian hospital which has been implementing the Ten Steps since the hospital's establishment in 2012. Fourteen midwives and nurses participated in a focus group in January 2020. Data were analyzed using thematic analysis. RESULTS: We identified five themes that represented midwives' and nurses' experiences of implementing the Ten Steps in this Indonesian maternity unit: 1) Human rights of child and mother, 2) Dependency on precarious leadership, 3) Lack of budget prioritization, 4) Fragmented and inconsistent implementation of the Ten Steps across the health system, and 5) Negotiating with family, community and culture. The results highlighted a dependency on local hospital champions and a lack of budget prioritization as barriers to implementation, as well as health system gaps which prevented the enablement of mothers and families to establish and maintain breastfeeding successfully in Indonesian maternity services. CONCLUSIONS: As Indonesia has one of the largest populations in South East Asia, it is an important market for infant milk formula, and health services are commonly targeted for marketing these products. This makes it especially important that the government invest strongly in Ten Steps implementation. Continuity of care within and across the health system and leadership continuity are key factors in reinforcing its implementation. The study findings from this Indonesian maternity care facility re-emphasize WHO recommendations to integrate the Ten Steps into national health systems and increase pre-service education on breastfeeding for health care professionals.

"We All Believe in Breastfeeding": Australian Midwives' Experience of Implementing the Baby Friendly Hospital Initiative.

BACKGROUND: The education and support of new mothers during the in-hospital stay for childbirth is a critical time to establish breastfeeding. The Baby-Friendly Hospital Initiative was launched in 1991 to encourage maternity services to support and educate mothers to breastfeed by implementing Ten Steps to Successful Breastfeeding. RESEARCH AIM: To explore midwives' experiences of implementing the Baby-Friendly Hospital Initiative in a Baby-Friendly accredited public hospital in Australia. METHODS: In this prospective, cross-sectional qualitative study we used focus groups to explore midwives' experiences. Midwives (N = 26) participated in two focus groups conducted between October and November 2019. Data were analyzed using thematic analysis. RESULTS: Time as a critical resource, and continuity of care, were crosscutting themes that framed midwives' experiences in supporting mothers to breastfeed their babies. Time constraints were experienced both through the health system structure and the BFHI accreditation process. Despite the challenges, the overarching theme-that we all believe in breastfeeding-fueled midwives' motivation. CONCLUSION: Health services policy and practice need to consider ways to enable continuity of midwifery care and adequate time for midwives to support women to breastfeed their babies.

The Social Value of Implementing the Ten Steps to Successful Breastfeeding in an Indonesian Hospital: A Case Study.

Background: Despite the known importance of breastfeeding for women's and children's health, global exclusive prevalence among infants under 6 months old is estimated at only 41%. In 2018, Indonesia had a lower exclusive breastfeeding rate of 37% at 6 months postpartum; ranging from 20% to 56%, showing unequal breastfeeding support throughout the country. The World Health Organization (WHO) launched the Ten Steps to Successful Breastfeeding (Ten Steps) in 1989, later embedded in UNICEF's Baby-Friendly Hospital Initiative (BFHI) program in 1991. The BFHI aims to encourage maternity facilities worldwide to ensure adequate education and support for breastfeeding mothers by adhering to the Ten Steps and complying with the International Code of Marketing of Breastmilk Substitutes. An Indonesian survey in 2011 found that less than one in 10 government hospitals implemented the Ten Steps. It has been common for Indonesian health services to collaborate with infant formula companies. While no Indonesian hospitals are currently BFHI-accredited, the WHO/UNICEF Ten Steps (updated in 2018) have been adopted in Indonesia's national regulation of maternity facilities since 2012. Internationally, implementation of the Ten Steps individually and as a package has been associated with benefits to breastfeeding rates and maternal and infant health. However, to date, few studies have examined the impact of implementing the Ten Steps in economic terms. This study aims to measure the economic benefit of Ten Steps implementation in an Indonesian hospital. Methods: The study was conducted in January 2020 in Airlangga University Hospital, Surabaya, Indonesia, which has implemented the Ten Steps since it was established in 2012. To understand and generate evidence on the social value of the Ten Steps, we conducted a "Social Return on Investment (SROI)" study of implementing the Ten Steps in this maternity facility. To estimate the costs relating to the Ten Steps we interviewed the financial and nursing managers, a senior pediatrician, and senior midwife due to their detailed understanding of the implementation of the Ten Steps in the hospital. The interview was guided by a questionnaire which we developed based on the 2018 WHO/UNICEF Ten Steps to Successful Breastfeeding. The analysis was supported with peer-reviewed literature on the benefits of Ten Steps breastfeeding outcomes. Results: The total per annum value of investment (cost) required to implement Ten Steps in Airlangga University Hospital was US$ 972,303. The estimate yearly benefit was US$ 22,642,661. The social return on the investment in implementing Ten Steps in this facility was calculated to be US$ 49 (sensitivity analysis: US$ 18-65). Thus, for every US$ 1 invested in Ten Steps implementation by Airlangga Hospital could be expected to generate approximately US$ 49 of benefit. Conclusions: Investment in the Ten Steps implementation in this Surabaya maternity facility produced a social value 49 times greater than the cost of investment. This provides novel evidence of breastfeeding as a public health tool, demonstrating the value of the investment, in terms of social impact for mothers, babies, families, communities, and countries. Breastfeeding has the potential to help address inequity throughout the lifetime by providing the equal best start to all infants regardless of their background. Indonesia's initial moves towards implementing the WHO/UNICEF Ten Steps can be strengthened by integrating all elements into the national regulation and health care system.

Social value of maintaining baby-friendly hospital initiative accreditation in Australia: case study.

BACKGROUND: Breastfeeding has positive impacts on the health, environment, and economic wealth of families and countries. The World Health Organization (WHO) launched the Baby Friendly Hospital Initiative (BFHI) in 1991 as a global program to incentivize maternity services to implement the Ten Steps to Successful Breastfeeding (Ten Steps). These were developed to ensure that maternity services remove barriers for mothers and families to successfully initiate breastfeeding and to continue breastfeeding through referral to community support after hospital discharge. While more than three in four births in Australia take place in public hospitals, in 2020 only 26% of Australian hospitals were BFHI-accredited. So what is the social return to investing in BFHI accreditation in Australia, and does it incentivize BFHI accreditation? This study aimed to examine the social value of maintaining the BFHI accreditation in one public maternity unit in Australia using the Social Return on Investment (SROI) framework. This novel method was developed in 2000 and measures social, environmental and economic outcomes of change using monetary values. METHOD: The study was non-experimental and was conducted in the maternity unit of Calvary Public Hospital, Canberra, an Australian BFHI-accredited public hospital with around 1000 births annually. This facility provided an opportunity to illustrate costs for maintaining BFHI accreditation in a relatively affluent urban population. Stakeholders considered within scope of the study were the mother-baby dyad and the maternity facility. We interviewed the hospital's Director of Maternity Services and the Clinical Midwifery Educator, guided by a structured questionnaire, which examined the cost (financial, time and other resources) and benefits of each of the Ten Steps. Analysis was informed by the Social Return on Investment (SROI) framework, which consists of mapping the stakeholders, identifying and valuing outcomes, establishing impact, calculating the ratio and conducting sensitivity analysis. This information was supplemented with micro costing studies from the literature that measure the benefits of the BFHI. RESULTS: The social return from the BFHI in this facility was calculated to be AU$ 1,375,050. The total investment required was AU$ 24,433 per year. Therefore, the SROI ratio was approximately AU$ 55:1 (sensitivity analysis: AU$ 16-112), which meant that every AU$1 invested in maintaining BFHI accreditation by this maternal and newborn care facility generated approximately AU$55 of benefit. CONCLUSIONS: Scaled up nationally, the BFHI could provide important benefits to the Australian health system and national economy. In this public hospital, the BFHI produced social value greater than the cost of investment, providing new evidence of its effectiveness and economic gains as a public health intervention. Our findings using a novel tool to calculate the social rate of return, indicate that the BHFI accreditation is an investment in the health and wellbeing of families, communities and the Australian economy, as well as in health equity.