Despite growing evidence for the positive impact of the Baby-Friendly Initiative (BFI) on breastfeeding outcomes, few studies have investigated the barriers and facilitators to the implementation of Baby-Friendly practices that can be used to improve uptake of the BFI at the local or country levels. This integrative review aimed to identify and synthesize information on the barriers, facilitators, and recommendations related to the BFI from the international, peer-reviewed literature. Thirteen databases were searched using the keywords Baby Friendly, Baby-Friendly Hospital Initiative, BFI, BFHI, Ten Steps, implementation, adoption, barriers, facilitators, and their combinations. A total of 45 English-language articles from 16 different countries met the inclusion criteria for the review. Data analysis was guided by Cooper's five stages of integrative research review. Using a multiple intervention program framework, findings were categorized into sociopolitical, organizational-level, and individual-level barriers and facilitators to implementing the BFI, as well as intra-, inter-, and extraorganizational recommendations for strengthening BFI implementation. A wide variety of obstacles and potential solutions to BFI implementation were identified. Findings suggest some priority issues to address when pursuing Baby-Friendly designation, including the endorsements of both local administrators and governmental policy makers, effective leadership of the practice change process, health care worker training, the marketing influence of formula companies, and integrating hospital and community health services. Framing the BFI as a complex, multilevel, evidence-based change process and using context-focused research implementation models to guide BFI implementation efforts may help identify effective strategies for promoting wider adoption of the BFI in health services.

Barriers, facilitators, and recommendations related to implementing the Baby-Friendly Initiative (BFI): an integrative review.

Background In 2011, South Africa committed to promoting exclusive breastfeeding (EBF) for six months for all mothers, regardless of HIV status, in line with World Health Organization recommendations. This was a marked shift from earlier policies, and with it, average EBF rates increased from less than 10% in 2011 to 32% by 2016. Objectives The aim of this mixed-methods systematic review was to describe EBF practices in South Africa and their multi-level influences over four policy periods. Methods We applied PRISMA guidelines according to a published protocol (Prospero: CRD42014010512). We searched seven databases [Africa-Wide, PubMed, Popline, PsychINFO, CINAHL, Global Health, and The Cochrane Library] and conducted hand searches for eligible articles (all study designs, conducted in South Africa and published between 1980–2018). The quality of articles was assessed using published tools, as appropriate. Separate policy analysis was conducted to delineate four distinct policy periods. We compared EBF rates by these periods. Then, applying a three-level ecological framework, we analysed EBF influences concurrently by method. Finally, the findings were synthesized to compare breastfeeding influences by policy period, maintaining an ecological framework. Results From an initial sample of 20,226 articles, 72 unique articles were reviewed, three of which contributed to both quantitative and qualitative analysis. Despite the large sample, several provinces were poorly represented (if at all) and many studies were assessed as low to moderate quality. Despite these limitations, our historical lens enabled us to explore why South African progress on increasing EBF practices has been slow. The review reflects a context that increasingly supports EBF, but falls short in accounting for family, community, and workplace influences. The findings also highlight the unintended damage caused by rapidly adopting and introducing global guidelines to an unsupported health workforce. Conclusions From a South African perspective, we identified geographic and methodological biases, as well as gaps in our understanding and potential explanations of inequities in EBF. Our recommendations relate to policy, programming, and research to inform changes that would be required to further improve EBF practice rates in South Africa. While our review is South Africa-specific, our findings have broader implications for investing in multi-level interventions and limiting how often infant feeding guidelines are changed.

/pdf/exclusive-breastfeeding-policy-practice-and-influences-in-4p1w7rhnur.pdf

Exclusive breastfeeding policy, practice and influences in South Africa, 1980 to 2018: A mixed-methods systematic review.

Improved breastfeeding practices have the potential to save the lives of over 823,000 children under 5 years old globally every year. The Baby-Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organization and the United Nations Children's Fund, which promotes best practice to support breastfeeding in maternity services. The Baby-Friendly Community Initiative (BFCI) grew out of step 10, with a focus on community-based implementation. The aim of this scoping review is to map and examine the evidence relating to the implementation of BFHI and BFCI globally.This scoping review was conducted according to the Joanna Briggs Institute methodology for scoping reviews. Inclusion criteria followed the Population, Concepts, Contexts approach. All articles were screened by two reviewers, using Covidence software. Data were charted according to: country, study design, setting, study population, BFHI steps, study aim and objectives, description of intervention, summary of results, barriers and enablers to implementation, evidence gaps, and recommendations. Qualitative and quantitative descriptive analyses were undertaken.A total of 278 articles were included in the review. Patterns identified were: i) national policy and health systems: effective and visible national leadership is needed, demonstrated with legislation, funding and policy; ii) hospital policy is crucial, especially in becoming breastfeeding friendly and neonatal care settings iii) implementation of specific steps; iv) the BFCI is implemented in only a few countries and government resources are needed to scale it; v) health worker breastfeeding knowledge and training needs strengthening to ensure long term changes in practice; vi) educational programmes for pregnant and postpartum women are essential for sustained exclusive breastfeeding. Evidence gaps include study design issues and need to improve the quality of breastfeeding data and to perform prevalence and longitudinal studies.At a national level, political support for BFHI implementation supports expansion of Baby-Friendly Hospitals. Ongoing quality assurance is essential, as is systematic (re)assessment of BFHI designated hospitals. Baby Friendly Hospitals should provide breastfeeding support that favours long-term healthcare relationships across the perinatal period. These results can help to support and further enable the effective implementation of BFHI and BFCI globally. 

https://internationalbreastfeedingjournal.biomedcentral.com/counter/pdf/10.1186/s13006-023-00556-2

Improving breastfeeding support through the implementation of the Baby-Friendly Hospital and Community Initiatives: a scoping review

English: The potential problems that HIV (human immunodeficiency virus) and AIDS (acquired immune deficiency syndrome) cause are multifaceted and can have devastating effects on a community. These problems are closely related to issues such as unemployment, poverty and co-morbidities. Another dilemma that is created by HIV involves the feeding of infants born to HIV-infected women, and it is especially the poor who experience the burden of this predicament.
In an ideal setting where resources are reliably available, it is recommended that HIV-infected mothers do not breastfeed as the risk of postnatal HIV transmission remains. The use of anti-retroviral medications can however, significantly decrease this risk. In resource-poor areas, such as in many South African communities, mothers are generally recommended to breastfeed. In these circumstances the safe and sustainable procurement and preparation of replacement feeds cannot be assured. It has been shown that the incorrect preparation of formula milk or the use of unsuitable breastmilk substitutes can notably increase infant mortality and morbidity, while breastfeeding has a major protective effect. Each HIV-infected pregnant woman must therefore weigh these options and attempt to make the best decision for her unique situation. Good quality counseling from health care workers is imperative to aid her in this process.
The purpose of this cross-sectional descriptive study was to investigate the knowledge, attitudes and practices of health care workers (n = 64) in the maternity wards of Pelonomi Regional Hospital in the Free State regarding infant feeding in the context of HIV. This was also determined in HIV-infected mothers (n = 100) who had recently given birth at the same health care institution.
The knowledge, attitudes and practices of health care workers were determined by means of self-administered questionnaires. The researcher completed the following questionnaires with the HIV-infected mothers during private structured interviews: socio-demography; household food security; anthropometry (infant / infants), reported health and medical histories (including infant / infants); knowledge, attitudes and practices regarding HIV and infant feeding; and, questions based on the 2010 WHO (World Health Organisation) Guidelines on HIV and Infant Feeding. Information that was obtained from patient files included in-hospital medication, CD4 cell counts and haemoglobin levels of mothers, as well as birth weight and birth length of infants.
The over-all level of knowledge of the health care workers related to infant feeding in the context of HIV was not adequate, when it is considered that they interact with and counsel HIV-infected women on a daily basis and should be very well-informed regarding all of the related issues. Few of them could comprehensively explain what ‘exclusive breastfeeding’ entails (6.7%). Many felt that they lacked practical knowledge related to breastfeeding, as 25.6% felt that they only had low to moderate confidence in showing a mother how to breastfeed, and 35.9% felt that they only had low to moderate confidence in showing a mother how to express breastmilk. However, most of the health care workers (89.1%) had a positive attitude towards South Africa promoting breastfeeding for infants of HIV-infected mothers if they cannot safely and sustainably procure formula milk.
Most of the mothers participating in this study were black, unmarried, unemployed and Sotho-speaking. Although most mothers lived in brick houses (84.0%) with access to electricity (83.0%) and tap water (96.0%), a large percentage of mothers indicated that food and money shortages do occur in their households (64.0%). However, very few mothers reported that they had a vegetable garden (23.0%) or owned livestock (4.0%).
Some of the mothers experienced symptoms such as chest pain (16.0%), diarrhoea (18.0%), loss of appetite (36.0%) and involuntary weight loss (11.0%). Hypertension was common in both mothers (26.0%) and their family members (42.0%). A large percentage of mothers had a relatively low (< 350 cells/mm3) CD4 count (46.3%), and a low (< 11.0 g/dL) haemoglobin level (37.3%), indicators of HIV disease progression and anaemia respectively. Approximately 25.0% of infants were classified as premature according to the WHO definition, and most mothers planned to breastfeed their infant/s (70.9%). The median z-scores for the length-for-age parameter in the full-term group (n = 75) was in the normal category, while the weight-for-age and weight-for-length parameters in the full-term group were slightly below the WHO median reference values. Twenty-six breastfeeding
problems were reported in total, with low milk production (38.5%) and sore breasts and
nipples (46.2%) the main breastfeeding problems that were experienced.
Most mothers correctly planned to wean their infants at six months, with the median value
for the introduction of both solids and liquids being six months. The majority lacked
adequate knowledge regarding general correct formula feeding practices, and when
mothers decided on formula feeding it was mainly done in an attempt to prevent postnatal
HIV transmission (76.7%).
A large percentage of the mothers were not aware of the fact that HIV can be transmitted
to an infant via breastfeeding (43.0%) even when anti-retroviral medications are used. They
knew that HIV-infected breastfeeding mothers should not practice mixed feeding (80.0%),
but they lacked knowledge related to the new WHO guidelines. As AFASS (affordable,
feasible, acceptable, sustainable, safe) criteria for formula feeding were not met by most
mothers, a large percentage of mothers correctly opted to breastfeed their infants. Almost
all of the mothers regarded animal milks such as cow’s milk as the least preferable infant
feeding option (83.0%). In general, counseling that mothers had received was not
adequate, or information was not retained by the mothers, since certain concepts related
to HIV and infant feeding could mostly not be described sufficiently. Only 16.7% of mothers
who chose to formula feed could comprehensively explain the correct procedure. Mothers
were mostly either ignorant or skeptical regarding expressed heat-treated breastmilk as an
infant feeding option (78.0%).
Nursing personnel were significantly more accepting of heat-treated expressed breastmilk
as an infant feeding method than the doctors and dieticians group combined (53.2% and
23.5% respectively), and they also felt a higher confidence in showing a mother how to
breastfeed (78.7 % and 58.8% respectively).
The age of the mothers did not influence their knowledge related to HIV and infant feeding
significantly. Mothers with higher educational levels were significantly more aware that HIV
can be transmitted via breastfeeding and they were also more concerned about transmitting HIV via breastfeeding than they were of the increased morbidity and mortality risks related to replacement feeding.
The provision of high quality counselling related to infant feeding and follow-up visits can improve the knowledge of HIV-infected mothers and lead to better infant feeding decisions being made. These actions will ultimately benefit both the mother and her infant.

Infant feeding within the context of HIV

/pdf/an-in-vitro-study-to-assess-three-different-sterilising-4r4c9drq9l.pdf

An in vitro study to assess three different sterilising methods for infant feeding cups and bottles

The Baby-Friendly Hospital Initiative (BFHI) is a global effort to improve the role of maternity services and to enable mothers to breastfeed their infants, thus ensuring the best start in life for their infants. The foundation for the BFHI is the Ten Steps to Successful Breastfeeding (BF). It has been shown, however, that the selective implementation of only some of the steps may be ineffective and discouraging to successful BF practices. An initial study was therefore conducted to assess the extent of the implementation of the Ten Steps in both public and private maternity facilities. Poor performance for some steps led to a follow-up study to investigate the knowledge and attitudes of health care workers (HCWs) and mothers alike and to evaluate the exclusive BF (EBF) practices of mothers attending private BF clinics. Both studies followed descriptive, cross-sectional designs and were set in the Cape Metropole in the Western Cape. Twenty-six maternity facilities participated in the initial study, for which observation lists were completed and verified by interviewer-administered questionnaires to both HCWs and mothers. Eighteen private BF clinics participated in the follow-up study, which included observations and interviewer-administered questionnaires to 25 HCWs and 64 mothers. During the initial study, lower mean scores were noted for Steps 1, 2, 6 and 10. The overall implementation of the Ten Steps was average. The findings highlighted the importance of the establishment and implementation of BF policies, of appropriate and continuous BF training and better referral systems to ensure initiation and establishment of early BF, EBF practices and support on an ongoing basis to ensure the best start in life for infants.

/pdf/breastfeeding-policies-and-practices-in-health-care-3336aa192c.pdf

Breastfeeding policies and practices in health care facilities in the Western Cape Province, South Africa

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Breastfeeding policies and practices in health care facilities in the Western Cape Province, South Africa