Reinvigorated Baby-Friendly Hospital Initiative Helps Promote Exclusive Breastfeeding in Malawi

This article was originally published by Health Policy Plus (HP+) here.

The Baby-Friendly Hospital Initiative (BFHI), led by WHO and UNICEF, aims to give newborns the best start in life by promoting exclusive breastfeeding from birth to six months. In Malawi, great strides were made after the initiative was first introduced in the country, with exclusive breastfeeding rates increasing from 3 percent in 1993 to 71 percent in 2010. However, the 2015-16 Malawi Demographic and Health Survey showed a decline to 61 percent, and in 2015, there were no longer any hospitals designated as baby-friendly in the country.

Malawi’s Ministry of Health and Population (MOHP) revitalized the BFHI in 2016 with support of the USAID Maternal and Child Survival Program (MCSP). When the MCSP ended in 2018, the Health Policy Plus (HP+) project took over the training and mentoring of hospitals following WHO’s revised BFHI curriculum. Based on lessons learned from MCSP, HP+ worked with the MOHP and USAID to adapt the approach and deliver trainings in nine district hospitals from 2018-19. These changes included:

  • Focusing on a few hospitals at a time and completing activities with each hospital before starting to work with a new set of hospitals
  • Providing immediate feedback as well as ongoing mentorship, coaching, and supervisory visits
  • Orienting 30 community promoters on the BFHI (in addition to the hospital staff trained in each district)
  • Ensuring that at least 80 percent of hospital staff are trained on the package, including both clinical and support staff, in a stand-alone training delivered in modules with a 5-day training for technical staff and two 2-day sessions for non-technical staff

As a result of the HP+-supported program, four hospitals have completed the initiative, passed the external assessment, and received accreditation as baby-friendly facilities. An additional five hospitals are undergoing mentorship and assessment. The MOHP has been involved in each step, ensuring continuity and institutional memory of the adapted HP+ approach.

Members of the BFHI taskforce pose in front of signs promoting breastfeeding in the maternity ward at Dedza District Hospital

At Dedza District Hospital, BFHI Coordinator and nurse Patricia Nkundulo leads the BFHI taskforce at the hospital, which monitors the clinical practices and management procedures that make up the ten steps to successful breastfeeding and ensures that mothers receive the information they need at the facility. The taskforce includes all cadres of staff in the facility (clinical, administrative, and security staff) so that monitoring is done at all levels.

According to Nkundulo, before the training, health workers didn’t know about the BFHI so messages about breastfeeding were not being shared with women who came to the facility to deliver their babies. Previously, they would tell women to breastfeed for six months without supplementing with other food or drinks, but they didn’t have the feeding tools or the ability to teach the skills—such as proper latching or milk expression—to make breastfeeding easier for women. Nkundulo explained, “in the past we allowed people to give drinks to the babies because we didn’t know the impact.”

Now, with 80 percent of the hospital staff trained, knowledge has been disseminated and spread to all the health workers. “Even the guards know about positioning [and] expressing. They’ll even tell people they see outside in the village who are breastfeeding their babies and have the position wrong,” said Nkundulo. She also observed that staff and patients are aware that exclusive breastfeeding for six months can be a family planning method.

Dedza District Hospital tracks a decline in neonatal mortalities, surpassing their target for 2019.

Training so many of the staff, including support staff like patient attendants, cleaners, guards, and cooks, has been helpful in the maternity ward, where task-shifting is a frequent occurrence. Sometimes only two nurses are available for 40 women. Tasks like counselling women in the antenatal clinic and maternity ward, providing health education, and demonstrating the correct positioning and attachment of the baby to the breast can be done by support staff. “If we just keep everything on us, nurses cannot manage,” Nkundulo explained. She has observed another benefit from the initiative: improvements in the relationships between hospital staff and patients.

Though difficult to attribute directly to the BFHI training, Dedza has seen a big reduction in neonatal deaths recently, from 24 percent in February to 13 percent in June. “A baby can die because of a lot of different conditions,” Nkundulo said. “If we have the knowledge and can teach women how to express [milk], we can reduce neonatal deaths from hypoglycaemia. If we teach them how to position and attach the baby, and they understand the importance of breastfeeding, we are going to reduce malnutrition. Dedza has been on the map for malnutrition, but I am sure that with the BFHI this will go down.”

The linkages to community promoters trained in the BFHI are also paying off. When women are discharged from the facility, they are instructed on where they can receive further support within their community. In the past, women would return to the hospital if they had problems, but now they are linked to health surveillance assistants and community promoters.

Nkundulo hopes that the facility will be able to sustain the progress made since the training, even if staff leave over time. “As of now, we are orienting each other. When there are new staff, we orient each other.” She hopes the facility will continue to support the full BFHI package. In the meantime, she and the other BFHI taskforce members will continue to train new staff on the approach themselves.

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