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Until recently child survival interventions were focused on programs such as universal child immunization, control of diarrheal diseases, growth monitoring and promotion. Little attention was paid to the role of breast feeding exclusively in reducing child infections, malnutrition and subsequent death. But with increasing, scientific knowledge of a strong positive correlation between improved breast feeding practices and reduction in infant mortality, morbidity and its nature of being baby-specific, it has been brought on the agenda and is being discussed by hospital facilities and community.(1) Despite the innumerable benefits which breast feeding can impart to mother its status remains poor in our state. Majority of women in Madhya Pradesh who breast feed their babies’ throwaway the first milk (colostrum) before they begin actual feed. Only 14.9% females feed within one hour of birth.(1) In 1992 WHO and UNICEF produced a set of guidelines called 10 steps aimed at changing practices in maternity facility so as to support breast feeding.(2) The global criteria for Breast Feeding Hospital Initiative (BFHI) serve as a standard for measuring adherence to 'each of the 10 steps for successful breast-feeding. In Indore only 2 hospitals have been given designation of Baby Friendly Hospital namely M.Y. hospital and District hospital (both are Government setups). This study has been designed to compare the working and practices of BFH and NBFH with regards to breast feeding practices in beneficiaries.
For the study 2 BFH namely MY Hospital and District Hospital and 2 NBF hospitals namely CHRC (Choithram Hospital and Research Centre) and ESI (Employee State Insurance) Hospitals were selected from the same city taking into consideration the size of hospitals and number of deliveries in these hospitals. From the selected hospitals 50 postnatal mothers were selected as beneficiaries from each hospital. Data was collected from the respondents using pre-designed and pretested questionnaires. Apart from the assessment made with the help of questionnaire based interview a passive observation checklist was made taking into consideration the following points.
Data Interpretation: All the options for each variables/question were given score, data entry was completed in the computer using SPSS Windows version 10 and master table was prepared, different tables, graphs were made to reflect the results. Survey data were analyzed using SPSS for windows.
On comparing the Baby friendly and Non baby friendly hospitals as per the ten steps of the baby friendly hospital initiatives we have found that (step 1) the written breast feeding policy is not present in any of the hospital and (step 2) and (step 3) training of the health care staff is present in only CHRC which is a Non baby friendly hospital where they impart training to the nurses about the breastfeeding practices and also inform all the pregnant women about the advantages of the breastfeeding. Practicing of the (step 4, 5, 6, 7, 8) initiation of breastfeeding within half an hour, Breastfeeding even if mother and child are to be kept separated, only exclusive breast feeding, Rooming in practices and Encourage on demand feeding practices are present in all the four hospitals but not up to the full extent. All the four hospitals discourage the use of artificial teats or pacifiers (step 9) and the (step 10) establishment of the mother support group is present in only CHRC in the form of lactation management unit which is also a Non baby friendly hospital (Table 1). Table 1: Comparison of Baby Friendly and Non Baby Friendly Hospitals as per the ten steps of Baby Friendly Hospital Initiatives
Out of total 200 postnatal mothers 78(39%) were primipara and 112 (61%) were multipara. 152 (81 BFH 71 NBFH) (76%) delivered by normal labour and 48 (19 BFH 29 NBFH) (24%) by Caessarian Section (LSCS). In 144 (72%) of the total 200 mothers the baby was given to mother after birth, 188 (94%) were informed about exclusive breast feeding (89 BFH, 99 NBFH) (p value <0.05), 177 (88.5%) were having knowledge about benefits of exclusive breast feeding (p value <0.05) (Table 2). Table 2: knowledge about the benefits of breastfeeding amongst postnatal mothers
89% of the beneficiaries of BFH were having positive attitude towards colostrum feeding in comparison to 97% of the beneficiaries of the NBFH (Graph 1). Out of total 200 postnatal mothers 60 beneficiaries had given first breastfeed to their babies within half an hour i.e. 21 beneficiaries from BFH and39 beneficiaries from NBFH (Graph 2).
24% of the beneficiaries of BFH and 45% of the beneficiaries of NBFH said Lower Segment Caesarean Section delivery to be the problem in initiation, whereas 27% from BFH and 31% from NBFH answered inadequate lactation (Table 3). Table 3: Reasons for delayed initiation of breastfeeding
71% beneficiaries from BFH and 74% beneficiaries from NBFH were practicing on demand feeding (Graph 3). Out of total 200 postnatal mothers 132 (66%) did not use prelacteals. 68(34%) had given prelacteals; 54(27%) water, 11(5.5%) honey, 03(1.5%) ghutti. 49 (24.5%) were taking normal meals; 97(48.5%) were taking Dalia; 05(2.5%) milk and liquid diet. On comparing the hospitals on the basis of the passive observation check list it was observed that the 10 essential steps were displayed only in D.H. None of the hospitals were practicing advertisement of Infant Milk Substitutes. Attitude of health care providers towards beneficiaries was helping and supportive. Only C.H.R.C. was having internal monitoring for their staff nurses. While observing for the correct positioning and placement of the baby it was found that out of 10 randomly selected mothers in the post natal ward 05 in M.Y.H., 04 in D.H., 05 in E.S.I.H., and 07 in C.H.R.C; were breastfeeding in correct positioning and placement (Table 4).
Table 4: Status of the hospitals as per the passive observation check list
Dasgupta A in their study reported that only 14.3% of the babies who were delivered normally were given their first breast feed in time, the ideal time of half an hour, while not a single baby delivered by caesarean section were given their breast feed within the stipulated time period of 4-6 hours.(3) Sanjay B Rao (et al) found in a study of mothers with a normal delivery breast feeding was initiated within half an hour in 8.6% patients and in 78% it was started within half to two hours. While in those with caesarean section breast feeding was initiated within 6 to 24 hours in 74% patients.(4) In our study 21% of the mothers of BFH and 39 of the mothers of NBFH were initiate breastfeeding within half an hour, so it is important that there should be a more consistent and effective Health Education System. Training material employ participatory discussion and relationship between attachments of the baby flow of milk, positioning and common breast feeding problems. The principles of exclusive breast feeding should not only be targeted at mothers but to their husbands and caretakers also, as they influence the beneficiaries a lot. Emotional & Psychological state of the mother is directly associated with breast feeding and breast milk production. In our study we found that the 41% of the mothers of BFH and 27% of the mothers of NBFH used prelacteals. A study conducted in 175 mothers at Kathmandu Medical College and teaching hospital by Malla KK and Malla T in 2002 revealed that the use of prelacteals was 6.9% amongst them.(5) AV Athvale (et al) conducted a study on factors influencing the time of initiation of breastfeeding on 200 mothers with new-born babies attending the out-patient department of Urban Health Centre, Government Medical College, Nagpur, were interviewed to find out the extent of influence of these factors on the initiation of breast feeding using a pre-tested questionnaire. Practices of giving pre-lacteals to the child and discarding colostrum were found significantly associated with delayed initiation of breast-feeding.(6) Shilpa, Lalitha, Prakash A, Rao S,(7) conducted a study to assess the impact of Baby friendly policies on lactation success, the feeding practices of out born babies were compared to inborn babies (Baby friendly hospital). No major differences were found in the duration and success of lactation among the 2 groups. More intensive efforts and public awareness is required if the ideals of a baby friendly hospital are to be met. The same we found in our study like training of the healthcare staff, informing the pregnant females about benefits of breastfeeding and lactation management unit is present in only those hospitals which are NBF In a study done by Okolo SN, Ogbonna C(8) by using a structured questionnaire based on 10 steps to successful breastfeeding in 250 health workers found that there were significant differences in the level of awareness among the doctors compared to the other categories of health staff. Fifty-two (20.8%) of the nurses were aware of the need for initiating breastfeeding within 30 min of birth and 92 (36.8%) were aware of breastfeeding support groups. The same we found in our study i.e. practicing of the (step 4, 5, 6, 7, 8) initiation of breastfeeding within half an hour, Breastfeeding even if mother and child are to be kept separated, only exclusive breast feeding, Rooming in practices and Encourage on demand feeding practices are present in all the four hospitals but not up to the full extent. This shows that there was general lack of awareness of some major recommended practices in the hospitals that will promote and sustain breastfeeding. Therefore there is the need for policy changes and BFHI training and monitoring of the staff of these health facilities to respond to the concern and growing need for proper infant/young child feeding. This will ensure that the status is kept in check. Support is necessary to those hospitals that are doing well as well as those whose standards are falling.
The concept of BFHI aims to prompt exclusive breast feeding particularly at hospitals setup. Even after 13 years of BHFI in Madhya Pradesh only 2 Hospitals of Indore have been accreditated as BFH. The trends of breast feeding practices in MP are also not satisfactory. The findings of the study shows that although designated as baby friendly, the breast feeding practices remained poor as compared to non baby friendly hospital. The fact that breastfeeding rates have generally improved even in non-baby-friendly health facilities may be indirectly influenced by the BFHI; its publicity and training programs for health professionals have raised public awareness of the benefits of breastfeeding, and the number of professional lactation counsellors has increased continuously. Still there is need to review the content & context of messages with the aim of improving the profile of aspect of Protection, Promotion, Support of Breast Feeding. It is very important that every health care provider spares enough time to discuss breast feeding among the beneficiaries. There is an utmost need to reinforce training of doctors and other paramedical staff members regarding BFHI. A constant monitoring and re-inspection is required at hospital level to have a check over the services imparted to beneficiaries.
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