Breastfeeding Survey among individual front line paediatricians and global National Mappings Preliminary draft, December 2013 Breastfeeding Contents Breastfeeding....................................................................................................... 2 Executive Summary............................................................................................. 3 Global Breastfeeding Survey ............................................................................... 4 Summary of National Mappings .......................................................................... 7 Appendix 1: Steering Group .............................................................................. 24 Appendix 2: Participants .................................................................................... 25 Appendix 3: The Baby Friendly Practice survey questionnaire ......................... 29 Appendix 4: The Baby Friendly Parents survey questionnaire ......................... 31 Supporting Associations 2 Executive Summary What did paediatricians think about breastfeeding in 2013? As part of the Globally Breastfeeding Summit 2013 preparations, the EiP Institute performed two complementary types of Market research. The first type was a survey among paediatric practitioners around the world. The purpose of it was to monitor their current level of compliance with the Baby Friendly Hospital criteria. That part of the preparation represents a brief scan of what the current practices are globally, regardless of what they perhaps ideally should be. The second type was a formal national mapping questionnaire to breastfeeding experts in specific target countries around the world. The purpose of the mapping exercise was to assess what the ongoing and potential opportunities are for the education of policymakers, healthcare professionals and parents, and to identify what the current maternity leave regulations are in different countries. The idea was to identify official documents, structures and educational processes which would already be well known by specialists. The results from these two pilot studies indicated potential improvement areas such as restricting the reserves of free samples of infant formula, ensuring that breastfeeding policies are properly displayed in waiting rooms, and designing waiting rooms so that women can find a place to breastfeed discreetly. Results also indicated that breastfeeding education may benefit from the development of a common global terminology for breastfeeding medicine, and from more interactive and engaging forms of breastfeeding education. Finally, and for the long term, policymakers and medical societies may benefit from working together to continue a global harmonisation of minimal maternity leave standards that would enable women to breastfeed their children without having to give up their work life. 3 Global Breastfeeding Survey Baby Friendly Practice Compliance The survey to individual paediatric healthcare professionals had the purpose to monitor to what extent the global paediatric community already complies with a set of clinical criteria called the Baby Friendly practice criteria. As a reference for the continued discussion, the Academy of Breastfeeding Medicine has suggested the following set of criteria to define a Baby Friendly Practice: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Establish a written baby friendly office policy Offer culturally and ethically competent care Introduce the subject of infant feeding in the first trimester Stop the use of any formula sampling or formula coupon distribution Encourage breastfeeding mothers to feed newborns only human milk Provide appropriate educational material on the benefits of breastfeeding Allow and encourage breastfeeding in your waiting room Do not display images of infants bottle-feeding Commend breastfeeding mothers at every consultation Encourage mother to exclusively breastfeed for 6 month Provide a lactation room for your employees (if feasible) Maintain a list of community resources for breastfeeding mothers (pump rental etc.) The survey was conducted in May – November 2013 among 1032 paediatric practitioners from 109 countries. The geographic representation of the respondents is indicated by continent in (Figure 1). Since the questions were mostly asked in a standardised multiple choice format, the results are presented as a set of pie charts (Figure 2). This form of presentation allows for a quick visual identification of areas with remaining and potentially widespread breastfeeding barriers. Figure 1. Geographic distribution of the 1032 respondents in the 2013 Baby Friendly Practice compliance survey among individual paediatric healthcare professionals. 4 In your clinic, do pregnant women receive information and leaflets about breastfeeding, which enable them to make an informed choice? If yes, is your breastfeeding policy displayed in the waiting room or other area where services are provided to mothers and babies? Is each member of staff aware of the policy? If so, are the benefits of breastfeeding included in the information? Does your clinic hold reserves of free samples of infant formula? Does your clinic have a written policy to support the promotion and protection of breastfeeding? Do lactating women receive these free samples of infant formula? Are you aware of the World Health Organisation Code of Marketing of Breast milk Substitutes? Does your clinic have posters that promote breastfeeding? Is your waiting room arranged in such a way as to provide a place where women can breastfeed discreetly? Is the hospital where most of your clients give birth an officially accredited Baby Friendly Hospital? Does your clinic refer clients to pre / post natal meetings? Does your clinic encourage women in their decision to continue breastfeeding when they return to the workplace? Figure 2. Questions on baby friendly practice compliance, and pie charts with results from globally collected responses. To facilitate a quick understanding of each result, the colour red was used throughout all plots to indicate what was the ideal anticipated response. Hence the larger the white or grey areas, the larger the potential remaining barrier. 5 Preliminary analysis It is encouraging to see that in all areas but one, over half of the responses were ‘red’, meaning they complied with the Baby Friendly Practice criteria. Even more encouraging, in 5 out of 13 analysed areas, over 75% of paediatricians indicated an already existing compliance. The five areas with the highest shares (>75%) of compliance were: 1. Clinics offer pregnant women information and leaflets about breastfeeding, which enable them to make an informed choice 2. The benefits of breastfeeding are included in the offered information 3. Paediatricians are widely aware of the World Health Organisation Code of Marketing of Breast milk Substitutes 4. Most clinics have posters that promote breastfeeding 5. A large majority of clinics encourage women in their decision to continue breastfeeding when they return to the workplace In the other end of the compliance scale, there are still areas with space for improvement. The only identified area with less than 50% compliance was the current formal accreditation status as a Baby Friendly Hospital. Possibly only a formality, but less than half of the hospitals where most children are born were accredited. Beyond that, the survey results showed less than 66% baby friendly compliance in four areas. These may therefore be referred to as improvement areas for 2014. 1. Many clinics still hold reserves of free samples of infant formula 2. Breastfeeding policies are still not often displayed in the waiting room 3. Many waiting rooms still lack a place where women can breastfeed discreetly 4. Many clinics do still not refer their clients to pre / post natal meetings Conclusions from the individual survey 2013 This is the first baby friendly compliance survey conducted by EiP, so there are yet no historical data to compare against to demonstrate global progress. That said, the starting point appears relatively encouraging given the over 50% compliance on nearly all assessed dimensions. For the future, paediatric healthcare providers may consider an increased attention on 1. Restricting the reserves of free samples of infant formula 2. Ensuring that breastfeeding policies are properly displayed in waiting rooms 3. Designing waiting rooms so that women can find a place there to breastfeed discreetly 6 Summary of National Mappings The individual interviews were performed in a large number of countries, so the average responses provide a global level indication, a global pulse which briefly indicates the status of general paediatrics within breastfeeding care. The mapping questions, on the other hand, indicated a more detailed situation in a limited number of specific target countries. These target countries have unique healthcare systems and responses therefore need to be understood in that context. The idea is that national situations may be better understood if mapping results are complemented with indications of current individual practice routines. The mapping questionnaire asked for an expert comment on over twenty parameters, categorised across three dimensions: A. Education of policymakers; B. Education of health care professionals; and C. Education of parents. The following twelve countries participated in the national mapping exercise, which was designed to collect national data from multiple and distantly located parts of the world, and with dramatically different population sizes and cultural profiles. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. China Czech Republic Iran Italy Lebanon Mexico Philippines Qatar Russia Saudi Arabia Spain United Arab Emirates (UAE) Summary of responses Responses were collected from a handful of regional breastfeeding experts. Some of the mapping questions were open-ended, with the result that the collected responses vary greatly in their length. A brief and simplified summary is therefore provided in the Tables 2-6 as an overview. 7 Table 2. Summary of national mapping responses: Education of policymakers Question CZECH REPUBLIC CHINA IRAN ITALY Dr. Nahid Ezoddin, and she is the chief manager of breastfeeding promotion committee of Iran. General Directorate for the Hygiene and Safety of Food and Nutrition, section n.5 ‘Nutrition’ ; Dr Roberto Copparoni, Dr Simona De Stefano and Dr Maria Antonietta Di Vincenzo LEBANON MEXICO PHILIPPINES National Breastfeeding Subcommittee Vicente Borja, National IYCF/ BF Coordinator QATAR RUSSIA SAUDI ARABIA SPAIN UAE A. Education of policymakers 1. Does your country have a named national breastfeeding policy coordinator? CNWCCW (China National Working Committee of Children and Women) Anna Mydlilová, National Centre of BF and Lactation League lLaktační Liga, Thomayer Hospital, Prague 1. Dr Walid Ammar, Director General of the Ministry of Public Health in Lebanon No Abolyan Lubov V, Federal Centre for the Promotion of breastfeeding, Ministry of Health Mr. Mehary Aldakhel Not at present Dr. Hajar Hosaini, Head of the MCH Ministry of Health. Dr. Khawla Naji, National Coordinator of the Breastfeeding Friendly Initiative 2. Dr Ali El Zein, President of the Lebanese Association of Early Childhood Development 2. Have there been any national, regional or local policy changes in your country, following your work to promote breastfeeding in the past 7 months? 1. Reassessment of Baby-friendly hospitals. 2. Started to establish a Baby-friendly Community with breastfeeding rooms in public areas (the Orange Ribbon Initiative) No Efforts to make the "first hour feeding" policy mandatory in the maternity hospitals. POMI (Progetto Obiettivo Materno Infantile) has not changed since 2003 National Infant and Young Child Nutrition Program A Protection Act of breastfeeding National Policies, Laws and Rules & Implementing Guidelines already in place 2012: Hospital BF policy became part of hospital accreditation. 2003: Policy for maternity & PHC The first donor milk bank is being planned. BF assessment plans development. Breastfeeding national policy committee established 6 months ago Not yet, but we are working with the Ministry of Health for future creation of a National Breastfeeding Committee. 3. National laws as supporters of Baby Friendly workplaces: what is the legally supported minimum maternity leave during and after pregnancy? 98 days after delivery 6-8 weeks before delivery, altogether 28 weeks (paid 70%). Optional leave up to 4 years with a fixed sum for 28 weeks up to 4 years. 9 months 5 months, full salary 42 days for private institutions, 60 days for governmental institutions 3 months (45 + 45 days before + after delivery) 14 weeks 2 Months for nationals.6 weeks for Expatriates 70 days single, 86 days complicated, 110 days twins 2 months for governmental and 45 days for nongovernmental female staff With one day parental leave 16 weeks Mona AbdulRahman, Training Coordinator at the Sharjah Baby Friendly Emirate campaign Baby Friendly Hospitals (no formulas in maternity wards). BF consultation on site, right to 1h BF off work hours. The WHO International Code was drafted as a new national law in UAE 2 months + 1h/day for BF at work, for 6 months (1 year in Sharjah) 8 Table 2. Summary of national mapping responses: Education of policymakers Question CHINA CZECH REPUBLIC IRAN ITALY LEBANON Support to fathers, for example: about one or two weeks leave The support of breastfeeding in the workplace. Clear breastfeeding policies in such environments. Increase BF initiation from 41.3% to 55% MEXICO PHILIPPINES QATAR Collaboration betweeen government, HCP organizations, and NGOs There is a need to develop or update National policy for BF. RUSSIA SAUDI ARABIA SPAIN UAE We are going to propose a new low concerning breastfeeding in public spaces Allow 2h for BF at work, increase the maternity leave to 12 months; paid leave for 4 months and 8 months half paid of unpaid. A. Education of policymakers 4. What (further) policy improvements would you suggest for 2014? 1. Maternity leave should be extension to 6 months. 2. Breastfeeding rooms to be established in all public areas for continued breastfeeding support after 6 months. 1. Long-termed breastfeeding; 2. No separation of mothers and babies 3. There is a problem concerning the law adoptation dealing with the marketing of breast milk substitutes. It is an important task for the next year support BFHI in newborns departments and the NICU for premature babies. Exclusive BF rate during 1st 6 months from 14.8% to 25% Increase exclusive BF rate during first 3 months from 27% to 35% Increase median BF duration from 11-12 months to 12-13 months - 10 suggestions, including develop central and regional programs for BF support 1. New policies to be included in the national policy e.g.: travel, hajj, emergencies, employees, and students. 2. Future plans to include lactation management in the medical student curriculum. 3. Standard breastfeeding clinic policy 9 Analysis: Education of policymakers Among the nine countries in the national mapping exercise, only two lacked a named national breastfeeding coordinator. Nearly all countries also reported recently taken steps in the national, regional or local policies following expert efforts to promote breastfeeding in the past seven months. All surveyed countries reported some form of legally established right to maternity leave in connection to child birth. As expected, the duration and exact configuration of leave dates varied between countries. Countries with relatively short maternity leaves reported time periods of around 2-3 months. Countries with more generous regulations allow for maternity leave up to four years, but at a fixed cost for the payer (essentially on your own expense). When opinions were invited on further desirable policy improvements, then experts suggested a wide range of topics to prioritise. These included modified regulations for the marketing of breast milk substitutes, support to fathers, and more complex programmes for central and regional support in larger countries. The next section assessed the breastfeeding education of healthcare professionals. The results are summarised in Table 3. 10 Table 3. Summary of national mapping responses: Education of health care professionals Question CHINA CZECH REPUBLIC IRAN ITALY LEBANON MEXICO PHILIPPINES QATAR Training course: Advanced Support for Breastfeedin g 1. Meetings –3 2. Congress- 2 3. Training – 3 4. Forum - 1 3 effective training courses/workshop s on BF Promotion, Support & Best practice in a Baby Friendly Hospital " RUSSIA SAUDI ARABIA SPAIN UAE Breastfeedin g counseling course WHO / UNECEF slandered 40 hour and 20 hour and decision maker course Our scientific association has organised a National Breastfeedin g Congress, and breastfeedin g courses for paediatrician trainees 1. Annual lactation consultant courses for physicians 2. Campaign at the Sharjah Supreme Council for family Affairs 2 x 40h courses Multiple 20h courses 2 x decision maker courses Ministry of health and ministry of National Guard - 13 training sessions - Joo Kean (WHO expert ICDC) in collaboration with the Ministry of Health, and Randa Saadeh (the National Baby Friendly Hospital Assessor) B. Education of health care professionals 5. What type of education has been produced for national, regional or local health care professionals in your country, following your work to promote breastfeeding in the past 7 months? 1. Training courses for MCH workers 2. Orange Ribbon initiative during World Breastfeeding Week World Week of Breastfeeding for 10 years. 5 conference s. Printed educational materials. Hot line and on line counseling. Website www.kojeni.cz 11 5+ b. Organiser Ministry of Health, China Association of Maternal and Child Health Care, China Society of Child Health Care, China Society of Pediatrics. National Lactation Centre (NARLAC) c. Number and type of participants (doctors/nurses/midwive s etc.) Pediatricians: 400 Midwives: 100 Nurses: 500 1500 health professionals, ca 500 lactation consultants mother- LCM for support mother to mother a. Number of events (of any size) Breastfeeding education is an obligatory part of all doctors' CME. - Medical universities, teachers usually neonatalogist s or paediatricians - - - About 100 1 113 9 3 9 Dr Arturo Giustardi (AICIP – Italian Association for the Care in Perinatology president) and his team Ministry of Health in collaboration with WHO and UNICEF Aprolam BFHI Program team at WH, Doha, Qatar. 1. The Academy of Medical Sciences 2. Department for feeding healthy and sick child FSBU " SCCH " RAMS 600 - 800 healthcare professionals involved with breastfeeding : midwives, neonatal and paediatric nurses, neonatologist s and paediatricians . 50 5,968 in total 1. Philippine Pediatric Society (PPS) 2. Association of Deans of Philippine College of Nursing 3. Save the Babies Coalition/ Arugaan 4. LATCH (A Peer Counselor Organization) Pediatricians Obstetricians Nurses Midwives Lactation counsellors Breastfeeding Advocates Health workers Public Mothers Deans and faculty of Nursing schools Professors Lawyers Doctors( Neonatology, Paediatric, Ob/Gyn ), Nurses, Midwives, Social workers 1200 doctors 250 researchers 200 medical residents 180 students 350 nurses 80 midwives 20-25 participants per course. health care professionals contact with mother and child health (Doctors, nurses, midwifes, health educators, dietitians) - In Sharjah, 90% of all HCP have been trained on the WHO/UNICE F Baby Friendly package 11 Table 3. Summary of national mapping responses: Education of health care professionals Question CZECH REPUBLIC CHINA IRAN ITALY LEBANON MEXICO PHILIPPINES QATAR RUSSIA SAUDI ARABIA SPAIN UAE B. Education of health care professionals d. Location of events Capital of 10 provinces, Capital of China(Beijing ) Prague Tehran Mainly Milan, Rome, Naples, Bari and Bolzano Regional Hospitals Various all over the country Hamad Bin Khalifa Medical City,Club hotel. Doha. Moscow, Moscow region, Kaliningrad, Krasnoyarsk. Tomsk, Yekaterinburg, Norilsk - - - e. Duration of events (as full days) 2 2 1 2 2 0.5 - 3 20 hours as per WHO/UNICEF standard 15 2-5 - 5 f. Breastfeeding topics covered See Table 5 See Table 5 3 days for residents in paediatrics, gynaecology and anaesthesia 1-2 days for nurses, midwives See Table 5 See Table 5 See Table 5 See Table 5 See Table 5 See Table 5 See Table 5 See Table 5 Not available Not available 6. Any key learnings to share from these events? Health professionals should be educated at school, also on counselling skills. Textbooks for pediatricians and nurses should be revised to include these topics. Establish a multidisciplinar y group for support BF, educators for education, lactation centre in each hospital, lactation consultant in hospitals, in NICU, payment LC service and aids (breast pump) from health insurance All of the above 1. There is growing interest in the interactive type of BF training by Dr Giustardi 2. he also sends updates in a bi-monthly newsletter to 100.000 contacts in the AICIP db. 3. He holds an annual national congress on education and science within breastfeeding and perinatal care. Participants especially Doctors should follow Paediatricendorsed WHO/UNIC EF “ Ten Steps to Successful Breastfeedin g” to promote breastfeedin g in all infants especially premature and LBW Max 2 days duration required as HCP cannot be out of service for longer. improvement on implementatio n and collaboration of government with health professional organizations and Nongovernment organization 1. Ability to save breastfeeding children with different diagnoses 2. The use of human milk fortifier for premature baby 3. The possibility of using donor milk 4. The need for breast milk banks in Russia 5. Implementatio n of the initiative " Baby Friendly Hospital " Counselling lactation mothers is the key for good lactation management s - - - 12 Table 3. Summary of national mapping responses: Education of health care professionals Question CHINA CZECH REPUBLIC IRAN ITALY LEBANON MEXICO PHILIPPINES QATAR RUSSIA No specialized magazine. In the journal " Current Pediatrics ", published by the Union of pediatricians of Russia, regularly publishes articles on breastfeeding. 1. Create Centers for breastfeeding SAUDI ARABIA SPAIN UAE B. Education of health care professionals 7. If there is a General medical (GP) journal in your country, what is the title ? Journal of China Child Health Care 1. CeskoSlovenska pediatrie 2. Ceska gynekologie 3. Bulletin of the Czech Pediatric Society Yes, “Breast Feeding Journal” Rivista ufficiale Società Italiana Medicina Generale, SIMG (Official journal of Italian Society of General Medicine) Lebanese Medical Journal Monthly BF lecture on CIBERPEDS (conapeme.o rg) None 1. QMJ – Qatar Medical Journal 2. Health Journal 3. Nabbd Alhayat + 2 other journals 8. What (further) educational improvements would you suggest for 2014? More training courses are needed for provincial trainers, and more training materials should also be printed for improved dissemination . Early postnatal bonding courses. Remove barriers to implementation 10 steps to successful BF, colostrum milk feeding in the special care Nursery, selfassessment questionnaire for BFHI in pediatric wards of hospitals, education and participation of pharmacies in the BFHIPharmacists as an Underutilized Resource for Improving CommunityLevel Support of Breastfeeding, education LPhealth professionals and mothers 1. To establish an on-line program to educate the public about different aspects of breastfeeding More education and training for students in paediatrics, midwifery and nursery, through the establishment of regular courses and meetings throughout Italy. 1. National policy for infant nutrition 2. At least 15 more Baby Friendly Hospitals 3. Increased maternity leave to 14 weeks 4. National Educational Programs for health care practitioners to attain Lactation Consultants 5. Social Networks for lactating mothers 6. Media support 7. Infant and young child nutrition in emergency situations Staff training on 1. Put up Breastfeeding Training Centers for those needing focused, specialized training in Lactation. 1. To continue to train all WH staff (services providers) & other relevant staff until all are trained using WHO/UNICEF training manual 2. Promote the “IBCLC” profession to ADPCN and MCNAP. 2. To develop a participatory action training program 2. To have regular educational programs for the public using the media: radio & TV, newspapers 2. Include BF lectures and workshops in medical student curricula. 3. Include BF in Postgraduate programs for doctors Yes many, e.g.: Saudi medical journal Revista Atención Primaria Emirates Medical Journal (free) Improvement (involve the ministry of higher education, ministry of education, in training) On-line course for paediatrician 1. More Extensive onsite training for the health workers and mother 2. More specialised Courses to follow the Basic Training Package 4. Introduce a BF doctor (consultant) post in all maternity hospitals and children's hospitals 13 Analysis: Education of health care professionals All nine countries reported multiple conducted breastfeeding training events and forms for healthcare professionals in the past 7 months. The type of event organisers varied between countries, but were typically either medical associations, universities, the Academy of Medical Sciences or its national equivalent in other countries. As such, the education appears to have held a high academic standard throughout the world. As expected, the largest volumes of training participants were found in countries with large populations sizes. One exception is however the Czech Republic which reported around 2,000 trained people despite being a relatively small country compared to Mexico, Russia and the Philippines. Training events were typically held either in the capital city or in several locations around the country. Suggestions for future improvements included more focus on multidisciplinary and highly interactive training forms, from which good experience were reported especially from Italy. More training on human milk bank establishment was also on the future agenda. All countries but Russia and the Philippines reported the availability of some form of national general medical journal. In Russia there is however a paediatric journal which is used for breastfeeding communications. The topics which were covered by national breastfeeding training sessions for healthcare professionals had some level of overlap, but also a relatively large diversity of content descriptors. This may reflect the lack of a yet wellestablished common medical nomenclature and terminology for breastfeeding topics, something that could potentially facilitate medical education programme harmonisation around the world. The detailed reported topics from various countries, harmonised where possible, are presented in Table 5. The next section assessed parent education on breastfeeding. The results are summarised in Table 4. 14 Table 4. Summary of national mapping responses: Education of parents Question CHINA CZECH REPUBLIC IRAN ITALY LEBANON MEXICO PHILIPPINES QATAR RUSSIA SAUDI ARABIA SPAIN UAE Breastfeeding campaigns in public area and big malls Various breastfeeding course for parents locally. In the Emirate of Sharja, the volunteer group Breastfeeding Friends organised meetings for mothers, 1-21counselling, and breast pump hire. There is also a hotline in 3 languages. Campaign by the Sharjah MCH Center C. Education of parents 9. What type of education has been produced for national, regional or local parents in your country, following your work to promote breastfeeding in the past 7 months? Events took place throughout the country, interest media, they were valued individuals and institutes support breastfeeding – Breastfeeding friendly Company a. Number of events (of any size) 100 Type of events Parents classes, Home visits by health workers, Dissemination of education materials. Leaflet for pregnant women – management BF, video for mother in hospitals, 20 regional events to celebrate the World week of BF, TV, radio, news paper Classes, email campaigns, advertising, articles, social media, etc. c. Organiser: Lactation League CR -LLCR. 10 000- LC, maternity centres, public- 1,8 mil. people -TV, radio… Most of our maternity hospitals have weekly or monthly classes to educate the pregnant women and their husbands for different aspects of breastfeeding. Weekly or monthly classes Around 30 events through Dr Giustardi 1 Baby Friendly Conference Media advertising all over the year, Mother to Mother group support all over the year Courses, movies, billboards, television and radio spots and meetings for two years for nursing mothers. - 1. Once a week group discussion on BF is done for women & pregnant ladies. 2. One by one at the wards & OPD clinic(Well baby clinic& Ob/Gyn) - 9 WeeklyGroup discussion at NICU. Daily at wards& units. 13 Many - Classes. Advertising in newspaper. Campaigns Popular Articles in magazines for parents, TV interviews, radio interviews, email campaigns. Campaigns, social media, T.V, newspapers, SMS massages, lectures, social, workshops, communications, lectures, small groups and large groups meeting, debates, role play, video, ppt, leaflets, brochures - 30 events through Dr Giustardi 2 major event s 35,000 educational packs 1 Ongoing talks in 900 hospitals 1. Major events: Philips AVENT invites mothers and fathers to attend a course on breastfeeding, held by a healthcare professional. 3. Educational packs: A guide on breastfeeding, samples of breastpads, and nipple cream classes, email campaigns, advertising, articles, social media Classes, email campaigns, advertising, articles, social networks Class Congress World BF Week Art exhibition Public campaign Letting activity National photo contest Newspaper article National TV guest Baby Friendly Campaign 1. Educational material, distributed at baby clinic visits 2. “Return to work” classes 3.Promitional items 4. DVD: “Best beginning from pregnancy to lactation” 5. Press, social media 6. Mobile mother room 15 Table 4. Summary of national mapping responses: Education of parents Question CHINA CZECH REPUBLIC IRAN ITALY LEBANON MEXICO PHILIPPINES QATAR RUSSIA SAUDI ARABIA SPAIN UAE C. Education of parents Duration of events Topics covered 10. Any key learnings to share from these events? Usually 0.5 days One week 3-4 hours 1/2 day (Dr Giustardi) 2 days (major events) 1 full day Max 2 hours 1-7 days See Table 6 See Table 6 See Table 6 See Table 6 See Table 6 See Table 6 See Table 6 More parenting classes need to be conducted and the breastfeeding counselling should be initiated in the hospital during pregnancy and after delivery. The events took place throughout the country, interest media, they were valued individuals and institutes support breastfeeding – Breastfeeding friendly Company All of the above Very important the interactive approach with mothers and fathers where, first of all, we create a relaxed atmosphere and we ask them to tell us about their knowledge and experience about breastfeeding, before going deeper into the subject in order to best answer to their needs. Breastfeeding education and follow up of pregnant women and mothers to be: prenatally, intranatally and postnatally through brochures and breastfeeding hotline Public participation is important, because this addresses their myths and FAQ. Better coordination with different stakeholders ( NGO, HCP organizations) 25 days See Table 6 See Table 6 1. The use of modern technologies to support and stimulate lactation 2. Creation of individual banks' breast milk 3. Ability to save breastfeeding children with different diagnoses Summer events, completed one month each year For breastfeeding week celebration: one week yearly For education lecture events: one hour, half day, Workshop: one day See Table 6 Key learning: the communities personals from different nationalities and different age groups, male and female all welling to support, promote and protect of breastfeeding if you talk with them - Variable. Also annual Ceremonies with certificates and gifts for mothers who completed two years breastfeeding Not available - Not available - 16 Table 4. Summary of national mapping responses: Education of parents Question CHINA CZECH REPUBLIC IRAN ITALY LEBANON MEXICO PHILIPPINES 1. Use of mass media for public education. 2. More concentration on normal vaginal delivery for reducing the rate of caesarean section. We are in the process of developing a video on breastfeeding which should be shown within all 500 maternities in Italy, so that mothers can see and learn practices on the correct positions on breastfeeding, on breast care, etc, and ask questions to the hospital staff if necessary. Breast feeding education programs including home visits should be standardized all over Lebanon Incorporation of breastfeeding education program in educational programs of all Lebanese Schools Include breastfeeding in school curricula, as part of personal health education Breastfeeding classes in all hospitals for future/ present mothers/parents. QATAR RUSSIA SAUDI ARABIA SPAIN UAE Audio-visual material for parents showing breastfeeding technique, breastfeeding extraction, etc. 1. Educational classes for parents as part of the prenatal routine check-up. 2. Extend the maternity leave to 4 months 3. On longer than 6h work shifts, allow for 2h breastfeeding during the 1st year of maternity C. Education of parents 11. What (further) educational improvements would you suggest for 2014? The breastfeeding supporting group need to be established in the community including the baby-friendly community initiative should be supported by local government to conduct the breastfeeding education. The media should be involved in the education events. Early postnatal bonding courses. Announcement of Actions chains (Akce řetěz) throughout the country, September 2014, celebration of World Breast week 1. Organise a future parents school in every district hospital for children 2. Conduct a series of BF lectures for expectant and present parents based in Centers for breastfeeding 3. Publication of popular BF articles for parents 4. BF advertising in the media and Broadcasting 5. Interdiction of infant formula advertising in the media. Educational improvement: initiate support group in each region and facilitate communication 17 Analysis: Education of parents As for the healthcare professional education, the largest parent education volumes were found in countries with large populations sizes. The largest activities were reported by Italy and Mexico, which both indicated training of thousands of parents in the past 7 months. Philippines and Russia both reported a smaller number of parent training events, but at least in the Russian case the duration was considerably longer, 25 days, than that reported from other countries. Provided the reported number is correct, then more details on this type of training would be useful to better understand how it works and what parent volumes it can educate effectively. Many countries limit the duration of the parent training to a few hours, but some may continue for up to a week. As for the professionals training, parent training events also took place on a country wide scale. Suggestions for future improvements included more public participation and interactivity in the breastfeeding training sessions. For parent education they also call for more use of videos and mass media, and inclusion of breastfeeding in school curricula as part of the personal health education. Popular science articles on breastfeeding are also requested as an important part of the parental education. The topics covered by national breastfeeding training sessions for parents were even less harmonised than the topics used to train the healthcare professionals. Details from various countries are presented in Table 6. 18 SAUDI ARABIA RUSSIA QATAR PHILIPPINES MEXICO LEBANON ITALY IRAN CHINA Question CZECH REPUBLIC Table 5. Summary of national mapping responses: Topics covered by the national breastfeeding education for healthcare professionals Topics covered in the national education of health care professionals National policies Troubleshooting: hypogalactia (milk shortage), nipple problems, and available aids such as feeding devices, Hand Expression & Breast pumps Breastfeeding basics and nursing position Baby-Friendly Hospital Initiative Breast anatomy and physiology including human milk composition Milk collection and Milk banks (Manual removal of milk) Maternal nutrition during pregnancy and lactation BF duration, weaning and complementary feeding Alternative breastfeeding methods Troubleshooting: BF contraindications such as HIV Immunological aspects of human milk and breastfeeding Mother kangaroo technique Troubleshooting: LM in children with cleft lip and palate BF in Emergencies and in the NICU Information on medication & breastfeeding. Protecting breastfeeding (Code of marketing) The Legal aspects for the code of marketing Special situations – premature babies Special situations – multiplets Special situations – Low Birth Weight Jaundice Storage and feeding All topics related to breastfeeding, including crying and sleeping patterns and their correlation to breast feeding. WHO /UNICEF manuals for participants, director, trainers Breastfeeding consultation Early skin- to-skin Contact Troubleshooting: The child is not gaining weight Troubleshooting: Digestive problems and breastfeeding 19 Table 5. Summary of national mapping responses: Topics covered by the national breastfeeding education for healthcare professionals Procedures for establishing Mother Kangaroo Program Neurodevelopment Co-sleeping syndrome and prevention of sudden infant death Emotional Impact of LM Cow 's milk protein allergy Working and Breastfeeding Prevention of obesity Troubleshooting: Infections and LM Humanized childbirth Troubleshooting: Contraception and LM Long-term effects Gastro esophageal reflux Risks of formula feeding LM Myths Technology and lactation Vaccines and Pregnancy and LM Well-start Breastfeeding Modules for its Integration to Pediatric Residency Curriculum Training Benefits of BF Anatomy & physiology of breast Getting started Common BF Problems Breastfeeding Benefits Essential Intrapartum and Newborn Care (EINC) Training Skin to skin during 1st hour Infant Feeding during Emergencies Well-start Breastfeeding Curriculum Risks of NOT BF What’s up in the media Communication skills (A tool for successful BF) Promoting breastfeeding during pregnancy How milk gets from breast to baby. Birth practices and breastfeeding. Breastfeeding of infant Special situations. Maternal health concerns Methods stimulating lactation 20 SAUDI ARABIA RUSSIA QATAR PHILIPPINES MEXICO LEBANON ITALY IRAN CHINA Question CZECH REPUBLIC Table 6. Summary of national mapping responses: Topics covered by the national breastfeeding education for parents Topics covered in the national education of parents BF support close to mothers Support groups Number of BF children Benefits of BF Nutrition during pregnancy Dental hygiene during pregnancy sport and pregnancy First hour feeding ( Skin to skin contact, breast crawl, suitable latching.. .) Umbilical cord care Breast feeding problem solving All aspects of BF, from nipple preparation during pregnancy to transition from BF to weaning. Particular focus on BF after C-section Lactation FAQ How to avoid problems How to fix the breast Breastfeeding technique Risks of NOT BF Getting Started Common BF problems Not enough milk? Disadvantages of not BF The skill of successful BF (Positioning, attachment. skin to skin). Why baby reluctant to BF Why mother do not BF Basics for successful BF Lack of breast milk (lactation stimulating techniques) Difficulties with breastfeeding ( lactostasis, mastitis, cracked nipples) Feeding with the expressed breast milk 21 Table 6. Summary of national mapping responses: Topics covered by the national breastfeeding education for parents The rules of creating an individual human-milk bank Allergy in breastfeeding, the possibility of its prevention Nutrition for nursing mother important of breastfeeding Hazards of formula feeding Mother support and Father Role Ten steps Breastfeeding in Islam Complementary feeding Successful breastfeeding tips Importance of early initiation lactation Importance of rooming in Saudi law points for public Exclusive breastfeeding Cup feeding and alternatives method Counselling Feeding cues Breastfeeding and work, breastfeeding and travel 22 Conclusions from the mapping exercise 2013 The mapping research from 2013 was successful in its global coverage of small and large countries from culturally and geographically very different environments. Countries with so different climates, population sizes and political systems are more likely than not to show significant differences also in the healthcare area. With this in mind, it is arguably encouraging to observe that all participating countries in this mapping exercise have significant ongoing activities to educate their parents, policymakers and professional healthcare audiences about the values and medical importance of breastfeeding. It is also encouraging to observe that most countries already have a named national breastfeeding coordinator and some form of legally established right to maternity leave for women in connection to child birth. There are also important areas which could, if addressed, further help improve the national and international breastfeeding rates. The most significant steps potential in this direction could be something along the following lines, presented here as inspiration for professionals who encounter breastfeeding questions as part of their daily practice, educational or policymaking work: 1. For the short term, medical societies at the national and international level could work together to develop a common vocabulary for breastfeeding medicine, with a clear terminology that could help establish breastfeeding medicine as an important and standardised part of professional medical education in any country. 2. For the short term, medical societies at the national and international level could also work together to develop more interactive and engaging forms of breastfeeding education, as this appears to be well received in environments where it has already been tested and it also seems to be in great demand from the other environments. 3. For the long term, policymakers and medical societies could work together to continue a global harmonisation of minimal maternity leave standards that would enable women to breastfeed their children without having to give up their work life 23 Appendix 1: Steering Group at the 2nd Global Breastfeeding Summit jointly held with the 1st Middle East Leaders' Forum on Breastfeeding STEERING COMMITTEE Dimitri A. Christakis, Co-Chair, Chairman of Excellence in Paediatrics Arthur Eidelman, Co-Chair, Professor of Pediatrics, Shaare Zedek Medical Center Richard Schanler, Co-Chair, American Academy of Pediatrics Section on Breastfeeding 24 Appendix 2: Participants at the 2nd Global Breastfeeding Summit jointly held with the 1st Middle East Leaders' Forum on Breastfeeding PARTICIPANTS BY COUNTRY China Yaohua Dai, Professor of Pediatrics, Capital Institute of Pediatrics Zhuang Wei, Head of Child Health Care Department, Beijing Children’s Hospital Affiliated to Capital Medical University Huishan Wang, Director of Children’s Health Care Department, National Center for Women and Children's Health Wei Zhang, Obstetrics & Gynaecological Hospital, Capital Medical University Zhu Zonghan, Professor of Pediatrics, Director of China Society of Pediatrics, former Director of Capital Institute of Pediatrics Bo Zhang, Section Head, Division of Child Health, Department of Maternal and Child Health, National Health and Family Planning Commission Leila Sabet, Paediatrician, Bejing United Family Hospital Czech Republic Jan Janda, Professor of Pediatrics, University Hospital Motol, PastPresident of the Czech Pediatric Society Jiri Nevoral, Pediatric Gastroenetrology and Nutrition, University Hospital Motol Zuzana Stromerova, Czech Confederation of Midwives, Midwife Milena Dvorakova, Czech Confederation of Midwives, Midwife Germany Silke Mader, Chairwoman of the Executive Board, EFCNI European Foundation for the Care of Newborn Infants Gerda Weiser, Nutricion and Breastfeeding Expert 25 Iran Italy Mohammad Kazemian, Pediatric Department, Neonatology Division, Shahid Beheshti University, Tehran Shahsanam Gheibi, Motahari Hospital, Urmia University of Medical Sciences Carla Paludetti, Breastfeeding Expert, representing Dr Giustardi, President of the Italian Association of Care in Perinatology (AICIP) Annalisa Ferraro, Professional Nurse, NICU Niguarda Hospital, Milan Lebanon Mariam Rajab, Pediatric and Neonatology Department, Makassed General Hospital, Beirut Mexico Horacio Reyes, Aprolam President, Pro Lactancia Materna Association Jesus Torres Saldivar, Paediatrician, Mexican Pediatric Society Ana Beatriz Rosas Sumano, General Coordinator of the National Pediatric Congress of CONAPEME Aurora Martinez Gonzalez, Vice President of Aprolam, Pro Lactancia Materna Association Maria Elena Luevano, Nurse, Baby Friendly Hospitals, National Coordinator of Milk Banks Mariana Colmenares, Certified Lactation Consultant IBCLC; Director of the Lactation Clinic, México City Hospital Silvia Guevara Contreras, Nurse, Baby Friendly Hospitals Ana Elena Limón Rojas, President of the Mexican Pediatric Association Oman Saada Mohammed Al Mamari, Senior Staff Nurse, Ministry of Health Nutrition, Department, Directorate General of Health Affairs (DGHA), Muscat The Philippines Cristina Bernardo, Head of Breastfeeding Committee, Philippine Pediatric Society Ryan Borja Capitulo, Philippine Obstetrical and Gynecological Society Poland Alicja Chybicka, President of the Polish Pediatric Society Wojciech Służewski, Department of Infectious Diseases and Child Neurology, University of Medical Sciences, Poznań Qatar Sis. Wilma Visda Bondoc, Head Nurse, Women's Hospital, Doha Sis. Elena Labtis Solis, Nurse, BF Programme, Women's Hospital, Doha 26 Saudi Arabia Yacob Al Mazrou, Secretary General, Ministry of Health, Riyadh Saleh Al-Muhsen, Associate Professor of Pediatrics, Department of Pediatrics, College of Medicine, King Saud University Nora Al-Kharji, Department of Family Medicine, King Abdul-Aziz Medical City, Riyadh Fouzia Al-Hreashy, Breastfeeding Promotion Committee at Family Medicine Department, National Guard Health Affairs (NGHA) Wafa Fallatah, Family Medicine Consultant, Lactation Consultant Abdulwahab Telmesani, Paediatrics Department, Umm Al-Qura University, Makkah Spain Marta Díaz Gomez, Coordinator, Breastfeeding Committee, Spanish Pediatric Association Susana Ares Segura, Pediatrician, University Hospital La Paz, Madrid Concepción de Alba Romero, Neonatologist, 12 de Octubre Hospital, Madrid UAE Hadia Radwan, Assistant Professor at University of Sharjah, College of Health Sciences Miriam Al Hosani, Family Physician, Ambulatory Health Services (AHS) SEHA Yousef Mohamed Adbulrazzaq Bastaki, Emeritus Professor of Paediatrics & Neonatology, Department of Paediatrics, College of Medicine & Health Sciences, UAE University, Al Ain Asmaa Alnuaimi, Consultant Pediatric Pulmonologist, Zayed Military Hospital Eiman Alkaff, Paediatric Department, Zayed Military Hospital Aysha Al Mutawa, Family Physician Hessa Alghazal Alsuwaidi, Director of Maternal and Child HealthSharjah/Executive Director of Sharjah Baby Friendly campaign Shahraban Abdulla, Consultant Paediatric Cardiologist of Latifa Hospital, Dubai Health Authority Fatma Sultan Al Olama, Head of Child Health Care Unit, Director of Lactation Management Training Courses, PPSPS Shamsa Abdul Manan Al-Awar, Assistant Professor, Department of OB/Gyn, CMHS College of Medicine and Health Science CMHS, Al Ain UK Terence Stephenson, Chair of the Academy of Medical Royal Colleges Atul Singhal, Professor of Paediatric Nutrition, ICH Nutrition Unit, Department of Nutritional & Surgical Science, Faculty of Population Health Sciences, London Mike Woolridge, Senior Lecturer in Infant Feeding School of Healthcare, Faculty of Medicine & Health, University of Leeds Teresa Kelly, Senior Research Midwife, NIHR Doctoral Research Fellow, Newcastle Hospitals NHS Foundation Trust & Newcastle University 27 USA Richard Schanler, Chair, American Academy of Paediatrics Section on Breastfeeding Jill Janke, Professor, Chair of Graduate Nursing Program University of Alaska Anchorage, representing AWHONN 28 Appendix 3: The Baby Friendly Practice survey questionnaire 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. What type of clinic practice is this? a. General Pediatric Clinic b. Family Practice Clinic c. Other _______________ Which geographic area is your clinic located in? a. Urban b. Suburban c. Rural d. Reservation e. Mobile f. Other What percentage of medicaid patients does your clinic see? a. >50% b. 25%-50% c. <25% d. None How many providers see patients at your clinic? ___________ How many patients does your clinic have? ________________ Does your clinic provide services to pregnant women? a. Yes b. No (if no, skip to question #8) If yes, do pregnant women receive information or leaflets about breastfeeding? (check all that apply) a. Yes, they are counseled on breastfeeding during appointments b. Yes, they receive information in a packet given to all pregnant women c. Yes, there is information available in the waiting room d. No e. I do not know Does your clinic have a written policy on breastfeeding? a. Yes b. No (if no, skip to question #11) If yes, is your breastfeeding policy displayed in the waiting room or other area where services are provided to mothers and babies? a. Yes b. No Are all staff members made aware of the policy? a. Yes b. No Does your clinic hold reserves of free samples of infant formula? a. Yes b. No (if no, skip to question #15) If yes, do breastfeeding women receive free samples of infant formula? a. Yes, they all do b. Yes, but only upon request or if medically indicated c. No Do women who are not breastfeeding (have chosen to formula feed) receive free samples of infant formula? a. Yes, they all do b. Yes, but only upon request 29 c. No 14. Does your clinic give free samples of formula to health professionals or other staff members? a. Yes b. No 15. Are you aware of the World Health Organization Code on Marketing of Breast Milk Substitutes? a. Yes b. No 16. Do you have magazines, leaflets or posters in your waiting room that advertise infant formula? a. Yes b. No 17. Does your clinic have posters that promote breastfeeding a. Yes b. No 18. Is your waiting room arranged in such a way that women can breastfeed discreetly? a. Yes b. No 19. Is there an area of the waiting room clearly designated for breastfeeding? a. Yes b. No 20. Does your clinic refer clients to breastfeeding classes or support groups? a. Yes b. No (if no, please skip to question #21) 21. If yes, are these classes or groups sponsored by infant formula companies? a. Yes b. No c. I do not know 22. Does your clinic employee a certified lactation consultant? a. Yes (if yes, please skip to question #23) b. No 23. If no, does your clinic have a place to refer women for help who are having difficulty with breastfeeding? a. Yes b. No 24. Is the hospital where most of your clients give birth officially certified as baby friendly? a. Yes b. No c. I do not know 25. Does your clinic encourage women in their decision to continue breastfeeding when they return to the workplace? a. Yes b. No 26. If a staff member wishes to breastfeed is she encouraged to do so, even during working hours? a. Yes b. No 27. Is there a private, non-restroom facility available for staff members to use during the day to express breast milk? a. Yes b. No 30 Appendix 4: The Baby Friendly Parents survey questionnaire Please answer all questions for your experience at your baby’s doctor’s office 28. Have you received any information or handouts about breastfeeding from your baby’s doctor or clinic? a. Yes b. No 29. Does your clinic have a written breastfeeding policy on display? a. Yes b. No c. I don’t know 30. Does your clinic have free samples of infant formula displayed in common areas? a. Yes b. No 31. Have you received a free sample of infant formula from the clinic? a. Yes b. No 32. Does your clinic have magazines, leaflets or posters in the waiting room that advertise infant formula? a. Yes b. No 33. Does your clinic have posters that promote breastfeeding? a. Yes b. No 34. Is your clinic’s waiting room arranged in such a way that women can breastfeed discreetly? a. Yes b. No 35. Does your clinic have a lactation consultant at the office to help with breastfeeding problems? a. Yes b. No c. I don’t know 36. If you had problems with breastfeeding, did your clinic refer you to someone for extra help? a. Yes b. No c. I did not have any problems d. I did not breastfeed 37. Did your clinic refer you to any class where you received information about infant formula in a group setting? a. Yes b. No 38. Did your clinic provide any information or resources about how to continue breastfeeding after you return to work? a. Yes b. No c. I do not work outside of the home d. I did not breastfeed 31
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