Health Professionals' Perspectives on Breastfeeding Support Practices.

BACKGROUND: The decrease in rates of exclusive breastfeeding has resulted in increased rates of infant mixed feeding. The WHO Baby-Friendly Hospital Initiative (BFHI) has been associated with significant increases in breastfeeding initiation and duration in maternity hospitals. However, little is known about whether or not the teaching hospital of the University of Dammam, Saudi Arabia, followed the ten steps recommended in the BFHI.
OBJECTIVES: This study was carried out to assess healthcare professionals' perspectives and opinions about the breastfeeding support practices at the teaching hospital.
MATERIALS AND METHODS: This research is a mixed methodology cross-sectional study carried out in the King Fahd Hospital of the University, Al-Khobar, Saudi Arabia. The first phase used a self-administered questionnaire to assess professionals' awareness and opinions about actual breastfeeding practices. The first phase results led to a qualitative interview design for the second phase. Descriptive statistics were used to describe and summarize the data. The chi-square test was used to examine the difference between the observed and expected frequencies of normal data.
RESULTS: There were no breastfeeding supporting policies followed at the hospital as per those recommended by BFHI. Mothers with breastfeeding problems were not referred for help and follow-up phone calls were not made to postpartum women after discharge. Healthcare professionals indicated that there were no hospital-based breastfeeding support groups, lactation consultants/specialists or lactation management unit available.
CONCLUSIONS: There is a need for breastfeeding support policies, practices and staff education to facilitate care consistent with the ten steps of the BFHI. Further study is needed to assess mothers' perspectives on breastfeeding approaches at the King Fahd Hospital of the University.

INTRODUCTION

Human breast milk is recognized worldwide as containing the ideal nutrition for young children.[123] According to the World Health Organization (WHO), exclusive breastfeeding for the first 6 months is recommended for infants. Breastfeeding is a natural evolutionary process. However, this does not always mean that this approach comes easily to every new mother.[145] Worldwide, the number of mothers wanting to breastfeed has declined in recent decades.[6]

Since 1990, the unveiling of the “Baby-Friendly Hospital Initiative” (BFHI) by the United Nations International Children's Emergency Fund (UNICEF) and WHO has encouraged healthcare and hospital facilities, in pediatric and maternity wards, to adopt practices that fully protect, promote and support exclusive breastfeeding from birth. To achieve accreditation as a Baby-Friendly Hospital, hospitals must meet the each of the ten steps for successful breastfeeding that make up the BFHI global criteria.[7]

Enhancing maternal healthcare is one of the eight Millennium Development Goals embraced by the global community in 2000.[8] As a result of discouragement related to hospitals' routine care and existing policies that are part of healthcare systems,[910] many mothers fail to reach their own breastfeeding goals. Evidence from developed and developing countries indicate that the BFHI has improved breastfeeding rates at the hospital level.[910]

Thus, to enhance breastfeeding and to solve uptake problems, it is important for healthcare providers to understand the factors that contribute to breastfeeding initiation and duration.[11] As demonstrated in previous study,[356] the low prevalence and short duration of breastfeeding both internationally and in Saudi Arabia have highlighted the need for additional intervention. The aim of this study is to assess the breastfeeding support practices from the target population at King Fahd Hospital of the University.

To obtain the Baby-Friendly Hospital designation, it is necessary to start with self-appraisal. This initial self-assessment analyzes the practices that encourage or hinder breastfeeding as well as determines the necessary changes required. For this reason, the current study assessed breastfeeding practices using the ten steps to successful breastfeeding, as outlined by the Baby-Friendly Initiative.

MATERIALS AND METHODS

This study was conducted using a mixed methodology comprising two phases: quantitative and qualitative. Data were collected from King Fahd Hospital of the University, Al-Khobar, Saudi Arabia, between November 2013 and July 2014. In the quantitative phase, participants included a convenience representative sample of 28 medical and nursing staff professionals, out of a total of fifty with administrative jobs in pediatric and maternity wards, who responded to the questionnaire. All were in positions where they are responsible for directly or indirectly promoting and supporting breastfeeding.

Ethical approval was granted by the Institutional Ethics Committee at University of Dammam. All participants received an information sheet about the purpose of the study and were required to sign a consent form. They were also informed that they were free to withdraw from the study at any time without explanation and without prejudice. Furthermore, there was no potential risk from participating in the study. Specifically, participation only involved questionnaire completion and where granted, participants were also interviewed by the researcher.

A cross-sectional study was designed to obtain information about the hospital's breastfeeding-related practices. Professionals' demographic features were also obtained. A questionnaire was used to collect the following data from healthcare professionals: (a) personal data including age, gender, educational level, position and experience and (b) professionals' awareness and opinions about actual breastfeeding practices.

The secretary of the medical hospital administration sent the self-administered questionnaires to all health professionals holding an administrative position (such as the Chairman of the Pediatric Department, Nursing Director and Medical Director), with a 56% response rate. At the same time, the nursing director's secretary sent the questionnaires to all hospital nursing supervisors who indirectly cared for women and infants as well as head nurses who directly cared for women and infants. Data were collected during the normal hospital day at each location. Therefore, participants maintained their positions while completing the questionnaire and returned it to the secretary. In addition, a sheet describing the purposes of the study was used to invite health professionals to complete the questionnaire.

In the qualitative phase, participants were drawn from the quantitative phase. For the purposes of the current research, homogeneous and purposive sampling was used. The sample was homogeneous because health professionals had all worked at the same hospital, provided care to pregnant and/or lactating women, experienced administrative work for the past two years, were willing to participate and had the capacity and time to come to the interview site. Each participant was assigned a fictitious name to maintain anonymity and confidentiality. To gather these data, face-to-face semi-structured interviews were conducted with a sample of five healthcare providers holding an administrative position who had volunteered to be interviewed. Interviews were carried out at a health professional's office. The interviews were conducted using a loosely structured interview schedule that addressed the main themes identified as missing in the existing literature. Themes for interview included the following: (1) factors that interfered with successful breastfeeding at the hospital, and (2) suggestions for improving breastfeeding practices at the hospital. All five interviews were conducted in English and were audio recorded following each participant's written permission. Field notes, including interviewers' descriptions of participants, were also transcribed and included as data.

Statistical analysis of the collected data was conducted using SPSS version 15 software (SPSS Inc., Chicago, IL, USA). Data collected during the quantitative study were entered and checked. Descriptive statistics such as frequencies, cross-tabulations and mathematical presentations were used to describe and summarize the data. The chi-square test was used to examine the difference between the observed and expected frequencies of nominal data. Statistical significance was set at a P ≤ 0.05.

Data from the qualitative phase were analyzed starting from first interview transcript before moving to the next interview. The data analysis process consisted of the following: Transcribing the interview; reading and rereading the transcript several times; and coding the data using MAXQDA qualitative software (version 12, Verbi Software, Berlin, Germany).

RESULTS

Twenty-eight healthcare professionals participated in the appraisal of BFHI at the hospital in Al-Khobar, Saudi Arabia. Participants' ages ranged from 28 to 59 years (mean ± standard deviation [SD] = 42.4 ± 10.24). Their years of experience ranged from 4 to 34 years (mean ± SD = 16.1 ± 10.17). The majority of professionals (92%) were nurses, and the rest were physicians. Most participants (75%) had obtained a bachelor degree.

Approximately, two-thirds (64%) of the hospital administrators stated that the hospital did not provide in-service breastfeeding-related training. One-fourth (29%) indicated that there was in-service training related to the advantages of breastfeeding in the form of seminars, workshops or conferences. As seen in Table 1, most healthcare workers stated that the hospital did not routinely offer breastfeeding support to mothers before or after delivery.

Table 1

Frequency distribution of types of breastfeeding support routinely offered to mothers before and after delivery (n = 28)

Breastfeeding support	Before n (%)		After n (%)
	Yes	No	Yes	No
Information on why breastfeeding is important	7 (25)	21 (75)	10 (35.7)	18 (64.3)
Information on how long breastfeeding should continue	7 (25)	21 (75)	9 (32.1)	19 (67.9)
Training on breastfeeding techniques	6 (21.4)	22 (78.6)	9 (32.1)	19 (67.9)
Training on breast milk expression and storage	6 (21.4)	22 (78.6)	8 (28.6)	20 (71.4)
Training on breastfeeding problems	7 (25)	21 (75)	8 (28.6)	20 (71.4)
Training on how to sustain breastfeeding when returning to work	4 (14.3)	24 (85.7)	7 (25)	21 (75)
Information on feeding alternatives to breastfeeding	7 (25)	21 (75)	8 (28.6)	20 (71.4)

Table 2 shows that most of the successful breastfeeding policies were not applied at the hospital. Nearly half of the healthcare professionals stated that mothers were not encouraged to breastfeed within 30 min following uncomplicated vaginal birth. Moreover, formula was provided to newborns before breastfeeding. Most healthcare professionals stated that formula milk was given to newborns in the nursery (82%) and mothers could not room with their infants 24 hours a day (71%). Referrals were not made to mothers with breastfeeding problems (68%). Furthermore, referrals were not made to appropriate breastfeeding resources at discharge (57%), and the hospital did not actively reach out through follow-up phone calls to mothers after discharge (79%). Healthcare workers agreed that there were no hospital-based breastfeeding support groups or lactation consultants/specialists (89%), no outside breastfeeding support groups (96.4%) and no lactation management unit available in the hospital (92%). Nearly half of the participants confirmed that breastfed infants were not allowed to use pacifiers, and breastfeeding on demand was encouraged.

Table 2

Administrative health professionals’ awareness of issues related to breastfeeding policies (n = 28)

Policy items	Yes n (%)	No n (%)	Sometimes n (%)
Asking mothers about their infants feeding plans during pregnancy	8 (29)	8 (29)	12 (43)
Encouraging initiating breastfeeding within half hour of uncomplicated vaginal birth	7 (25)	16 (57)	5 (18)
Prelacteal foods are given to newborns before breastfeeding	13 (46)	9 (32)	6 (21)
Artificial milk is given to newborns in the nursery	23 (82)	2 (7)	3 (11)
Breastfed infants allowed to use pacifiers	9 (32)	14 (50)	5 (18)
Allowing 24 hours a day (rooming-in)	5 (18)	20 (71)	3 (11)
Only giving breast milk to breastfed infants	6 (21)	19 (68)	3 (11)
Encouraging breastfeeding on demand	12 (43)	13 (46.4)	3 (11)
Referral of mothers with breastfeeding problems	6 (21)	19 (68)	3 (11)
Referral of mothers to appropriate breastfeeding resources at discharge	7 (25)	16 (57)	5 (18)
Postpartum follow-up visit	16 (57)	7 (25)	5 (18)
Active reaching out: Patient follow-up phone call after discharge	3 (11)	22 (79)	3 (11)
Hospital-based breastfeeding support group or lactation consultant/specialist	3 (10.7)	25 (89.3)	NA
Other breastfeeding support groups	1 (3.6)	27 (96.4)	NA
Lactation management unit available in the hospital	2 (7.1)	26 (92.9)	NA

NA – Not available

As evident in Table 3, healthcare professionals working in pediatric, maternity and other departments agreed there was an absence of nearly all hospital-based breastfeeding support policies. Awareness level of breastfeeding policies among members of the pediatric, maternity and other departments was not statistically significant. Except for allowing 24 hours a day (rooming-in), specifically all Maternity Department staff stated that there was no rooming-in compared to nearly half of both pediatric and other staff which was statistically significant (P = 0.01).

Table 3

Cross-tabulation of perceptions of interviewed healthcare professionals on issues related to breastfeeding policies by department (n = 28)

Characteristics	Maternity department n (%)	Pediatric department n (%)	Others n (%)	P
Asking mothers about their infant feeding plans during pregnancy
Yes	3 (33)	2 (20)	3 (33)	0.13
No	1 (11)	2 (20)	5 (56)
Sometimes	5 (56)	6 (60)	1 (11)
Total	9 (100)	10 (100)	9 (100)
Encouraging initiating breastfeeding within half hour of uncomplicated vaginal birth
Yes	2 (22)	3 (30)	2 (22)	0.95
No	6 (67)	5 (50)	5 (56)
Sometimes	1 (11)	2 (20)	2 (22)
Total	9 (100)	10 (100)	9 (100)
Prelacteal foods are given to newborns before breastfeeding
Yes	7 (78)	3 (30)	3 (33)	0.088
No	1 (11)	3 (30)	5 (56)
Sometimes	1 (11)	4 (40)	1 (11)
Total	9 (100)	10 (100)	9 (100)
Artificial milk is given to newborns in the nursery
Yes	9 (100)	7 (70)	7 (78)	0.513
No	0 (0)	1 (10)	1 (11)
Sometimes	0 (0)	2 (20)	1 (11)
Total	9 (100)	10 (100)	9 (100)
Breastfed infants are allowed to use pacifiers
Yes	2 (22)	5 (50)	2 (22)	0.517
No	6 (67)	3 (30)	5 (56)
Sometimes	1 (11)	2 (20)	2 (22)
Total	9 (100)	10 (100)	9 (100)
Allowing 24 hours a day (rooming-in)
Yes	0 (0)	4 (40)	1 (11)	0.014*
No	9 (100)	6 (60)	5 (56)
Sometimes	0 (0)	0 (0)	3 (33)
Total	9 (100)	10 (100)	9 (100)
Only giving breast milk to breastfed infants
Yes	1 (11)	3 (30)	2 (22)	0.460
No	8 (89)	5 (50)	6 (67)
Sometimes	0 (0)	2 (20)	1 (11)
Total	9 (100)	10 (100)	9 (100)
Encouraging breastfeeding on demand
Yes	4 (44)	5 (50)	3 (33)	0.554
No	3 (33)	5 (50)	5 (56)
Sometimes	2 (22)	0 (0)	1 (11)
Total	9 (100)	10 (100)	9 (100)
Referral of mothers with breastfeeding problems
Yes	2 (22)	1 (10)	3 (33)	0.140
No	7 (78)	6 (60)	6 (67)
Sometimes	0 (0)	3 (30)	0 (0)
Total	9 (100)	10 (100)	9 (100)
Referral of mothers to appropriate breastfeeding resources at discharge
Yes	2 (22)	2 (20)	3 (33)	0.754
No	6 (67)	5 (50)	5 (56)
Sometimes	1 (11)	3 (30)	1 (11)
Total	9 (100)	10 (100)	9 (100)
Postpartum follow-up visit
Yes	6 (67)	6 (60)	4 (44)	0.888
No	2 (22)	2 (20)	3 (33)
Sometimes	1 (11)	2 (20)	2 (22)
Total	9 (100)	10 (100)	9 (100)
Active reaching out: Patient follow-up phone call to after discharge
Yes	1 (11)	1 (10)	1 (11)	0.737
No	7 (78)	7 (70)	8 (89)
Sometimes	1 (11)	2 (20)	0 (0)
Total	9 (100)	10 (100)	9 (100)
Hospital-based breastfeeding support group or lactation consultant/specialist
Yes	1 (11)	1 (10)	1 (11)
No	8 (89)	9 (90)	8 (89)	0.996
Total	9 (100)	10 (100)	9 (100)
Other breastfeeding support groups
Yes	0 (0)	0 (0)	1 (11)	0.335
No	9 (100)	10 (100)	8 (89)
Total	9 (100)	10 (100)	9 (100)
Lactation management unit available in the hospital
Yes	0 (0)	1 (10)	1 (11)	0.598
No	9 (100)	9 (90)	8 (89)
Total	9 (100)	10 (100)	9 (100)

*Statistically significant (P = 0.01)

A total of five health professionals ranging in age from 30 to 55 years participated in the semi-structured interviews in the qualitative phase. Participants included three women and two men. All participants had worked at the hospital for 5 years or more. Data analysis was immediate and done manually as thematic analysis. The field notes and transcription was read many times. Analysis was done manually and counterchecked a few times, thematic analysis was done and data were color coded, categories and subcategories formed and themes formulated. Data suggested that there were three main reasons for interference with breastfeeding initiation at the hospital. Specifically, these included the following themes.

Lack of breastfeeding education

There was a lack of breastfeeding education for mothers and the staff who cared for them, for instance, Participant I stated that “nobody in the hospital is responsible for educating the women about breastfeeding.” This participant also indicated that there is “no in-service training program for breastfeeding education for the health staff.”

Absence of a hospital-based breastfeeding support team. As stated by Participant V, there is “no breastfeeding support group in this hospital, not even in the newborn unit, we need help in this issue. I will say that very seldom the health education department runs breastfeeding education in the hospital, being honest with you we need a trained team for breastfeeding support.”

The hospital's routine policy is to use formula feeding. For instance, Participant II said that “the newborn baby is separated from his/her mum and kept in the nursery for routine care that is starting with glucose and then formula milk.”

In the qualitative phase, participants provided many suggestions that can be summarized as follows:

“Ok let me tell you…in order to solve the problem of breastfeeding initiation in the hospital and help, we need public and academic orientation about what do you mean by the Baby-Friendly Hospital. Health teaching about breastfeeding should start from the prenatal period (Participant III).”

“Provide programs for mothers to increase their awareness” (Participant IV).

“There must be a continuous campaign program for this matter” (Participant I).

“To appoint specialized people to train for breastfeeding” (Participant II).

“A follow-up clinic with a breastfeeding consultant or specialist is highly needed in our hospital to help all mothers with some complications that might arise, and we have nobody to help” (Participant I).

DISCUSSION

International studies have identified factors that affect the initiation and duration of breastfeeding. Some of these factors are associated with healthcare professionals who can influence mothers' breastfeeding behaviors.[1213] As indicated by percentages of participants in agreement, the current study revealed that the hospital's support system did not provide in-service training to healthcare professionals (64%) who were directly involved in maternal and child healthcare. Our study indicates most healthcare professionals were not trained to support mothers with successful breastfeeding.

In a UK study, McFadden et al. found that there was a gap between what mothers needed and what the healthcare professionals provided in terms of infant feeding. As a result, short courses were provided to health professionals by volunteers, organizations or individuals from the UNICEF Baby-Friendly Initiative and others. This education was provided in a variety of forms including seminars, workshops, online (e.g., through e-mails) and with written materials.[14]

Another issue found in both quantitative and qualitative studies is that the policy of supplementation of feeding. Using formula is one of the main factors contributing to the decline in breastfeeding rates within the latter half of the first year of infants' lives. This procedure has been shown to negatively affect the initiation and duration of breastfeeding practices.[81516] The provision of free samples of formula to health workers and hospitals in Saudi Arabia by milk and food product companies encourages and supports these practices.[161718] According to most of the healthcare professionals at the hospital (82%), artificial milk was given to newborns in the nursery.

The UNICEF Baby-Friendly Initiative indicated that the two main factors that interfered with breastfeeding rates during the 20th century were “the marketing activities of manufacturers of breast milk substitutes and hospital practices that undermined the establishment of breastfeeding.”[8] In contrast, with the suggested protocol (Step 4 of BFHI), nearly half of the participants in our study stated that breastfeeding was not encouraged within half an hour after an uncomplicated delivery.[19] Furthermore, the study revealed that prelacteal foods were given to newborns as their initial food. Subsequently, this practice in poor countries puts newborns at great risk for developing diarrhea and other infectious diseases in the future if the mother continues using artificial milk (either combined or not combined with breastfeeding).[20]

Many studies have emphasized the importance of applying step seven, the “practice rooming-in which allows mothers and infants to remain together 24 hours a day.” This greatly affects successful breastfeeding initiation and increases duration.[21] However, in the current study, 71% of participants indicated that rooming-in was not allowed at the hospital as a result of the lack of appropriate policies and because the hospital is not equipped to room infants with their mothers.

Mothers who delivered in maternity units fully accredited as Baby Friendly were 10% more likely to start breastfeeding than others.[222324] Many studies have also reported that implementing the ten steps and continuing support after delivery were important factors for increasing the rates of exclusive breastfeeding initiation at local, national and global levels. Indeed, the implementation of the BFHI has been associated with significant increases in breastfeeding initiation and duration in maternity hospitals.[1025]

In the current study, it was clearly demonstrated that no breastfeeding support policies were followed at the hospital. There were a number of participants that indicated that mothers with breastfeeding problems were not referred for help (68%) or followed up with a phone call following discharge (79%). In addition, healthcare professionals agreed that there was no hospital-based breastfeeding support group or lactation consultant/specialist (89%) nor lactation management unit available in the hospital (92%).

A number of studies have found that the issue is not only to establish policies but also to assess how policies are applied and counter potential obstacles to their implementation that could arise from either mothers or professionals.[26]

Worldwide, it is crucial for all mothers to understand the benefits of breast milk and risks associated with using artificial milk, especially in countries where breastfeeding was previously a norm, and there would have little problem returning to this practice.[27] As mentioned in the UNICEF nutrition website, “optimal breastfeeding of infants under 2 years of age has the greatest potential impact on child survival of all preventive interventions, with the potential to prevent over 800,000 deaths (13% of all deaths) in children under five in the developing world.”[28] There are few references of published studies about the decline of breastfeeding rates (initiation and duration) in Saudi Arabia, especially from the local region.[27] The findings would emphasize the urgent need to adopt BFHI policies in the university hospital.

CONCLUSIONS

To enable the hospital to provide care consistent with the ten BFHI steps, there is a need for changes in breastfeeding policies, practices, staff attitudes and education. This study also suggests the importance of having knowledgeable and supportive staff in Saudi Arabia (including lactation consultants) that can assist women who have recently given birth to overcome various breastfeeding-related obstacles. It is recognized that there are some barriers between healthcare professionals and postnatal women for initiation of breastfeeding due to the practice of introducing formula milk soon after birth. Further studies are recommended on mother's perspectives on breastfeeding support they received at their hospitals before and after birth.

Financial support and sponsorship

The authors would like to thank for the financial support provided through the Deanship of Scientific Research.

Conflicts of interest

There are no conflicts of interest.