Background
Every facility providing maternity services and care for newborn infants should: | |
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1. | Have a written breastfeeding policy that is routinely communicated to all healthcare staff. |
2. | Train all healthcare staff in skills necessary to implement this policy. |
3. | Inform all pregnant women about the benefits and management of breastfeeding. |
4. | Help mothers initiate breastfeeding within one half-hour of birth.a |
5. | Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants. |
6. | Give newborn infants no food or drink other than breast-milk, unless medically indicated. |
7. | Practice rooming in - that is, allow mothers and infants to remain together 24 hrs a day. |
8. | Encourage breastfeeding on demand. |
9. | Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. |
10. | Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. |
A natural birth experience is a significant prerequisite for successful breastfeeding. Therefore, mother-friendly care is a compulsory part of BFHI-certification. The criteria require, unless medically indicated that: | |
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a) | Mothers can bring a companion of their choice to provide continuous physical and/or emotional support during labor and birth, as desired. |
b) | Mothers can drink and eat light foods during labor, as desired. |
c) | Mothers can walk and move about during labor, as desired. |
d) | Mothers can choose a position while giving birth. |
e) | Mothers should be offered the use of non-drug methods of pain relief. |
f) | Invasive procedures such as rupture of the membranes, episiotomies, acceleration or induction of labor, instrumental deliveries, or caesarean sections should be used only for medical indications. |
g) | Standards, guidelines and training curricula of the maternity unit support mother-friendly care. |
Methods
Study design
Setting
Study participants and recruitment
Participant and occupation | Gender | Position | Years of work experience | ||||
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Female | Male | Management | Non-executive | <5 years | 5–15 years | >15 years | |
Hospital Aa (N = 14) | |||||||
Physicians (N = 5) | 5 | 1 | 4 | 1 | 2 | 2 | |
Midwives (N = 5) | 5 | 1 | 4 | 2 | 3 | ||
Nurses (N = 4) | 4 | 1 | 3 | 1 | 3 | ||
Hospital Ba (N = 11) | |||||||
Physicians (N = 4) | 3 | 1 | 1 | 3 | 2 | 2 | |
Midwives (N = 3) | 3 | 1 | 2 | 1 | 2 | ||
Nurses (N = 4) | 4 | 2 | 2 | 1 | 3 | ||
Hospital C (N = 11) | |||||||
Physicians (N = 4) | 3 | 1 | 1 | 3 | 2 | 2 | |
Midwives (N = 3) | 3 | 1 | 2 | 1 | 2 | ||
Nurses (N = 3) | 3 | 1 | 2 | 3 | |||
Quality manager (N = 1) | 1 | 1 | 1 |
Data collection
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What is your role in relation to the implementation of the BFHI?
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What are your general views on and opinions about the BFHI?
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What are the challenges that your hospital experienced in becoming Baby-Friendly?
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How were barriers overcome?
Data analysis
Ethical issues
Results
Theme | Sub-theme | Professional group | Verbal quote |
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Theme 1: Health professionals’ approaches to childbirth and breastfeeding | Medicalization of childbirth and breastfeeding | N7 | … and of course, sometimes you intervene, you can’t help it. |
N8 | … one is used to give a bottle when mothers say they think to have insufficient breastmilk, because then breastfeeding problems are settled. Convincing mothers and supporting them that they don’t stop, but rather continue, that’s really difficult. | ||
M11 | There are nurses, child nurses [on the ward]. There are lactation counselors, those who are IBCLC-certified, but often it’s these strict rules rather than caring on an individual basis… | ||
P12 | Of course, I’m convinced about the benefits of breastfeeding and women should possibly be supported to be able to breastfeed. Even after discharge, they should still wish to breastfeed rather than stopping it because they’re too stressed. It’s good […] for their [babies’] physical condition. For the immune response and the like and for mothers… | ||
M8 | Besides, I’ve the impression that nipple shields are used quite fast and quite often… I don’t know the specific reasons, whether it’s then easier for nurses to support breastfeeding. | ||
Naturalness of childbirth and breastfeeding | P1 | Midwives also provide reasons for it [BFHI] and [they outline] that it’s very important for the bonding between mother and baby, that this is really substantial. Concerning antibodies, we know from medicine that it’s relevant… [Midwives emphasize] again and again, that it’s crucial for the close relationship between mother and baby. | |
M8 | If the mother has delivered under my supervision and if I’ve seen that breastfeeding works without nipple shields but this [giving nipple shields] will be the first intervention after 3 h, I’ll go to the nurse and ask her directly why this is necessary? | ||
M3 | This whole process starts with increasing salivation among babies. Fascinating, really and due to this oozy cheeks they can slip to it, I mean, you have to consider this, how genial nature is. | ||
M10 | Give [mothers] security that nature has prepared them. Of course there are sometimes exceptions, that not every mother can [breastfeed]. | ||
Theme 2: Collaboration in the face of professional and structural boundaries | Professional jurisdictions | N5 | After c-section, you need the anesthesiologist, the gynecologist, the pediatrician, the midwife, sometimes an additional nurse … The problem about this is again, these habitual jurisdictions… |
N7 | Because when there are lactation problems, then you’ve to ask for a gynecologist, because this problem is a problem that relates to mothers, thus, mother issues, they relate to gynecologists. | ||
P7 | Because it [delivery] changes the focus, I become less and less interesting as gynecologist, before, I’m the most interesting person for the mother. | ||
P10 | Following our system, it’s midwives who are responsible for the labor room and who take care of mothers up to a few hours after delivery. Then mothers will be handed over to nurses. From then on, nurses are responsible for taking care and counselling. | ||
M10 | … there is some little exchange [between midwives and nurses] when moving mothers from the labor room to the ward. Otherwise, there is hardly any exchange, well, we’re really separated divisions. | ||
P7 | … because we don’t have any executive power. Anesthesiologists have their work area and are responsible for this area. In the beginning they said, no one is allowed to enter the operating theatre because they are responsible. In the end, you run against a wall and you can’t overcome it because it’s right, it’s his [the anesthesiologist’s] area. | ||
P2 | As we’re [gynecologists] only responsible for ward rounds on the maternity ward and as we aren’t present on the ward the whole day, it [breastfeeding counseling] belongs to the responsibility of the respective nurse… | ||
P10 | As long as they [mothers] have no baby, I’m not involved as a pediatrician. I don’t know, we’ve discussed repeatedly how much of an issue breastfeeding is once women reach the end of their pregnancy. | ||
Spatial division of maternity units | N9 | They’re really isolated in their labor room although the labor room and the ward are next to each other. To get to the labor room, you even have to pass the ward, but still, we don’t know every name of every midwife… there isn’t a strong connection. | |
P13 | Because during daily work there outside [on the ward], I think… | ||
M10 | But it would make sense to handover all issues which we’ve [midwives] already explained to her [the mother], which breastfeeding position we’ve shown, thus a little bit more elaborated. Also outside on the ward, … there should be more explicit handovers | ||
Theme 3: Strategies to harmonize professional approaches with BFHI implementation | Safeguarding and defense strategies | N2 | … you have a standard which specifies who does what, where does he/she conduct it, when is it conducted. |
N6 | If you don’t have any standards or any points of reference or how shall I say, guidelines, it’ll slip somehow and after a while you’ll return to old practices. | ||
M10 | Well it’s just, probably to shape it consistently, there are standards, and then the individual interpretation is often neglected [by nurses]. Well, I hardly appreciate that. | ||
M11 | For me, Baby-Friendly means to act in an individual manner, but… nurses want to hear: if this than that, and that. But this isn’t applicable to breastfeeding and maternity and child care. | ||
Circumvention strategies | M3 | However, even in my case, there are aspects [of BFHI] which I refuse. For example, the standard or guideline that every woman has to get skin-to-skin contact directly after c-section, I cannot sign this. | |
N9 | … the anesthesiologists, they think, it [BFHI] isn’t relevant to them… they think it [BFHI] won’t bother them. | ||
P1 | I can only remember that during one night shift it was said at 3.00 am, that we’ve to do skin-to skin contact. I’ve to say, I’ve denied it. Everything was so exciting and the father ran around | ||
P1 | Well we, the anesthesiologists hardly have to do anything with it [BFHI)… | ||
N9 | Well, it’s, midwives are really self-confident, it’s a really self-confident professional group. | ||
P13 | The team of gynecologists is quite fragmented. Really fragmented, there is a break between advocates and refusers, i.e. physicians who don’t feel responsible for breastfeeding. |
Theme 1: Health professionals’ approaches to childbirth and breastfeeding
Medicalization of childbirth and breastfeeding
Naturalness of childbirth and breastfeeding
Theme 2: Collaboration in the face of professional and structural boundaries
Professional jurisdictions
Spatial division of maternity units
Theme 3: Strategies to harmonize professional approaches with BFHI
Safeguarding and defense strategies
Circumvention strategies
Discussion
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Inter-professional exchange of monitoring and documentation data: Monitoring and documenting the specific concerns of professionals that, for example, hinder skin-to-skin contact after c-section, as well as the attitudes and interpretations of particular BFHI-content among professional groups, can help to create a mutual understanding of the BFHI and facilitate collaboration [24]. This strategy can help to overcome the problem of timely sharing of knowledge. Yet, emphasis should be placed on sharing this information on an inter-professional basis. For example, in line with findings from Walsh et al. [17], documenting reasons for the provision of formula feeding should be discussed, at least among nurses and physicians, as they are currently those who are responsible for mother-baby dyads on the ward.
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Regular inter-professional team meetings: The BFHI in Austria recommends the establishment of an inter-professional BFHI project group. This can be used as a starting point to establish regular inter-professional team meetings whose lack was emphasized by our interviewees. Such meeting could help to share perceptions of and experiences with BFHI-related activities. Further research is needed, to investigate how such meetings can be established and sustained over time.
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Inter-professional training activities: Training of health professional represents a fundamental prerequisite for maternity units to achieve BFHI-certification. The relevance of training to facilitate BFHI implementation has been emphasized previously [24, 38]. The Austrian BFHI certification authority defined the scope of training as 20 h for midwives and nurses, 10 h for physicians and 4 h for nursing assistants working in the maternity units. However, our data indicated that professionals remain within their professional jurisdictions and experience difficulties to overcome these jurisdictions in order to collaboratively implement BFHI. One option to make professionals familiar with BFHI-related activities and collaborative practices are inter-professional training activities. Such training activities should be used as an opportunity to discuss professionals’ different approaches to childbirth and breastfeeding as well as ways to integrate BFHI. It is important to stress that training activities should pay particular attention to enabling midwives, nurses, and physicians to learn how to work together and how to collaboratively integrate the BFHI into practice. A BFHI-simulation training can probably enhance current training activities. In this respect, Watters et al. [39] have shown that inter-professional simulation training of midwives, nurses, and physicians in the UK enhances inter-professional communication and teamwork.