Baby-friendly hospital initiative training course for maternity staff: director's guide

BABY-FRIENDLY HOSPITAL INITIATIVE TRAINING COURSE FOR MATERNITY STAFF Director’s Guide Baby-friendly Hospital Initiative training course for maternity staff: director's guide ISBN (WHO) 978-92-4-000893-9 (electronic version) ISBN (WHO) 978-92-4-000894-6 (print version) © World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 This joint report reflects the activities of the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO or UNICEF endorses any specific organization, products or services. 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO or UNICEF be liable for damages arising from its use. Design by Thahira Shireen Mustafa Photo credits: © WHO/Gato Borrero Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide iii CONTENTS ACKNOWLEDGEMENTS ............................................................................................................ v ABBREVIATIONS .................................................................................................................... vi GLOSSARY .......................................................................................................................... vii 1. COURSE INTRODUCTION ....................................................................................................... 1 1.1 COURSE RATIONALE .............................................................................................................................................................................. 1 1.2 COURSE OBJECTIVES ............................................................................................................................................................................ 3 1.3 TARGET AUDIENCE ................................................................................................................................................................................ 3 1.4 PARTICIPANT’S COMPETENCIES: TRAINING AND FOLLOW-UP ..................................................................................................................... 4 1.5 COURSE STRUCTURE .......................................................................................................................................................................... 10 1.5.1 Session order ........................................................................................................................................................................ 10 1.6 COURSE MATERIALS ........................................................................................................................................................................... 10 1.6.1 Director’s guide ...................................................................................................................................................................... 10 1.6.2 Trainer's guide ....................................................................................................................................................................... 10 1.6.3 Slides (PowerPoint) ............................................................................................................................................................... 10 1.6.4 Participant's manual............................................................................................................................................................... 10 1.6.5 Forms and checklists ............................................................................................................................................................. 10 1.6.6 Answer sheets ........................................................................................................................................................................ 11 1.6.7 Updates .................................................................................................................................................................................. 11 1.6.8 Training aids .......................................................................................................................................................................... 11 1.7 REFERENCE MATERIALS ....................................................................................................................................................................... 13 1.8 CLERICAL AND LOGISTICAL SUPPORT .................................................................................................................................................... 15 1.9 FUNDS REQUIRED ............................................................................................................................................................................... 16 1.10 CEREMONIES: OPENING AND CLOSING ................................................................................................................................................ 16 1.11 COURSE DIRECTOR’S ROLE ................................................................................................................................................................ 16 2. ARRANGEMENTS: COURSE LOCATION ...................................................................................... 18 2.1 CLASSROOM FACILITIES ...................................................................................................................................................................... 18 2.2 ACCOMMODATION AND MEALS ............................................................................................................................................................ 18 2.3 SITES FOR CLINICAL PRACTICAL SESSIONS ............................................................................................................................................ 18 2.3.1 Health facility visit .................................................................................................................................................................. 19 2.3.2 Prepare the facility staff ......................................................................................................................................................... 19 3. SELECTING TRAINERS AND PARTICIPANTS ................................................................................ 21 3.1 SELECTING TRAINERS .......................................................................................................................................................................... 21 3.1.1 Trainer's profile ...................................................................................................................................................................... 21 3.1.2 Inviting trainers ...................................................................................................................................................................... 21 3.2 PREPARING TRAINERS ......................................................................................................................................................................... 21 3.2.1 Outline of course training methods ....................................................................................................................................... 22 3.2.2 Methods used and training skills required ........................................................................................................................... 23 3.2.3 Review the Trainer's guide and the other materials .............................................................................................................. 25 3.2.4 Practising the sessions .......................................................................................................................................................... 25 3.2.5 Review the timetable .............................................................................................................................................................. 26 3.2.6 Visit sites for practical sessions ............................................................................................................................................ 26 3.2.7 Thank the trainers for their efforts ......................................................................................................................................... 27 3.2.8 Trainers’ meetings ................................................................................................................................................................. 27 3.3 SELECTING PARTICIPANTS ................................................................................................................................................................... 28 3.4 SAMPLE: COURSE ANNOUNCEMENT ..................................................................................................................................................... 29 4. PLANNING CHECKLISTS ....................................................................................................... 30 4.1 CHECKLIST: OVERALL PLANNING .......................................................................................................................................................... 30 4.1.1 Initial planning ....................................................................................................................................................................... 30 4.1.2 Arrangements before the course begins ............................................................................................................................... 32 4.1.3 Actions during the preparation of trainers ............................................................................................................................ 32 4.1.4 Actions during the course ..................................................................................................................................................... 32 Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide iv 4.2 CHECKLIST: COURSE MATERIALS ......................................................................................................................................................... 34 4.3 CHECKLIST: EQUIPMENT AND STATIONERY ............................................................................................................................................ 35 4.4 CHECKLIST: ITEMS NEEDED FOR DEMONSTRATION ................................................................................................................................. 35 4.4.1 General ................................................................................................................................................................................... 35 4.4.2 Individual sessions ................................................................................................................................................................ 35 4.5 CHECKLIST: BACKGROUND INFORMATION NEEDED ................................................................................................................................. 37 4.6 SAMPLE TIMETABLE ............................................................................................................................................................................ 37 4.7 SAMPLE: COURSE TIMETABLE (HELD OVER 3 DAYS) ............................................................................................................................... 38 5. COURSE TOOLS TO PHOTOCOPY ............................................................................................. 39 5.1 REGISTRATION AND EVALUATION .......................................................................................................................................................... 39 5.2 JOB AIDS AND CHECKLISTS .................................................................................................................................................................. 46 5.3 OTHER ITEMS OF KEY INFORMATION ..................................................................................................................................................... 61 5.4 DEMONSTRATION AND SCRIPTS FOR ROLE PLAY ..................................................................................................................................... 66 5.5 ANSWER SHEETS ................................................................................................................................................................................ 74 TABLES TABLE 1. COURSE COMPETENCIES ............................................................................................................................................................... 5 TABLE 2. HOW TO MAKE A MODEL DOLL ..................................................................................................................................................... 11 TABLE 3. HOW TO MAKE A MODEL BREAST .................................................................................................................................................. 12 TABLE 4: EXAMPLE OF AN INFORMATION SHEET FOR A CLINICAL PRACTICE SITE ........................................................................................... 20 (TO BE ADAPTED ACCORDING TO THE CONTENT AND CONTEXT OF THE COURSE) ......................................................................................... 20 TABLE 5. EXAMPLE OF COURSE ANNOUNCEMENT ......................................................................................................................................... 29 TABLE 6. CHECKLIST FOR COURSE MATERIALS ............................................................................................................................................ 34 TABLE 7. COURSE MATERIALS TO BE PHOTOCOPIED ..................................................................................................................................... 34 TABLE 8. CHECKLIST FOR EQUIPMENT AND STATIONERY ............................................................................................................................... 35 TABLE 7. EXAMPLE OF COURSE TIMETABLE ................................................................................................................................................. 38 Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide v Acknowledgements The development of this training curriculum was coordinated by the World Health Organization (WHO) Department of Nutrition and Food Safety, and the United Nations Children’s Fund (UNICEF) Nutrition Section, Programme Division. Thahira Shireen Mustafa, Laurence Grummer-Strawn, and Maaike Arts oversaw the revision of this training curriculum. This training curriculum is an update of the 2009 Baby-friendly Hospital Initiative (BFHI) training materials. Heather Rusi and Dana Hardy provided support in revising the package of the materials. We also thank the guidance and inputs provided the Advisory Commmittee members for this revision process (in alphabetical order): Decalie Brown, Felicity Savage, Hiroko Hongo, Marina Ferreira Rea, Mona Abdulrahman Alsumaie, Mudiwah Kadeshe. The updated materials were used in a pilot training jointly organized by WHO and UNICEF in collaboration with Ministry of Health and Family Welfare, Government of India. The pilot training was held from 11 – 14 March 2019 at Postgraduate Institute of Medical Education and Research and Dr. Ram Manohar Lohia Hospital, New Delhi, India. We appreciate the extensive support provided by Arti Maria, Angela de Silva, Gayatri Singh, and Rachita Gupta, along with the staff of WHO and UNICEF Country offices in India and Sri Lanka and the staff of Dr. Ram Manohar Lohia Hospital, New Delhi, India in organizing this pilot-training. Acknowledgement is given to all the resource persons who participated as trainers and facilitators during the training including (in alphabetical order): Dana Hardy, Dhammica Rowel, Dulanie Gunesekera Siriwardene, Nethmini Thenuwara, Preethi Sainia, Shacchee Baweja, and Sila Deb. Special thanks to the many colleagues who participated in the training and provided extensive and valuable comments and suggestions to improve the training materials (in alphabetical order): Alka Mathur, Amlin Shukla, Anita Gupta, Anita Rajorhia, Bahunshisha Kharkongor, Basant, Bhupinder Kaur, Isha Thapar, Jassal, Krishna Bhattacharya, Kriti Jain, Manathunga, Mutum Shanti, Navita, Nidhi Chopra, Preeti Sainia, Priya Gandhi, Pushpamma Sebastian, Reetu Singh, Rohini Sehgal, Ruchika Chugh Sachdeva, Sanarei Thangal, Sangeeta Rani, Sarita Bhagwat, Sebanti Ghosh, Shweta, Sonu Mishra, Sudha, Susan, Tapas Bandyopadhyay, and Veena Bahri. We also greatly appreciate the technical input received from the members of the Baby-Friendly Hospital Initiative (BFHI) Network, International Baby Food Action Network (IBFAN), International Lactation Consultants Association (ILCA), La Leche League International (LLLI) and World Alliance for Breastfeeding Action (WABA) during the revision process of the training materials. WHO gratefully acknowledges the financial contribution of the Bill & Melinda Gates Foundation, the Ministry of Health and Welfare, Republic of Korea and the United States Agency for International Development towards the preparation of this training curriculum. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide vi Abbreviations ART antiretroviral therapy ARV antiretroviral BFHI Baby-friendly Hospital Initiative HIV human immunodeficiency virus IgA immunoglobulin A IgG immunoglobulin G TB tuberculosis UNICEF United Nations Children’s Fund WHA World Health Assembly WHO World Health Organization Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide vii Glossary Afterpains: Contraction of the uterus during breastfeeding in the first few days after childbirth, owing to release of oxytocin. Allergy: Symptoms when fed even a small amount of a particular food (so it is not dose related). Alveoli: Small sacs of milk-secreting cells in the breast. Amenorrhea: Absence of menstruation. Anaemia: Lack of red cells or lack of haemoglobin in the blood. Antenatal preparation: Preparation of a mother for the delivery of her baby. Antibodies: Proteins in the blood and in breast milk that fight infection. Appropriate touch: Touching somebody in a socially acceptable way. Areola: Dark skin surrounding the nipple. Artificial feeding: Feeding an infant on a breast-milk substitute. Artificial feeds: Any kind of milk or other liquid given instead of breastfeeding. Artificial teat: The part of a feeding bottle from which a baby sucks. Artificially fed: Receiving artificial feeds only, and no breast milk. Attachment: The way a baby takes the breast into his/her mouth; a baby may be well attached or poorly attached to the breast. Baby-friendly Hospital Initiative (BFHI): An approach to transforming maternity practices as recommended in the joint World Health Organization (WHO)/United Nations Children’s Fund (UNICEF) statement on Protecting, promoting and supporting breastfeeding: the special role of maternity services (1989). 1 Bilirubin: Yellow breakdown products of haemoglobin, which cause jaundice. Blocked duct: A milk duct in the breast becoming blocked with thickened milk, so that the milk in that part of the breast does not flow out. Bonding: Development of a close loving relationship between a mother and her baby. Bottle-feeding: Feeding an infant from a bottle, whatever is in the bottle, including expressed breast milk, water, formula, etc. Breast pump: Device for expressing milk. 1 Protecting, promoting and supporting breastfeeding: the special role of maternity services. A joint WHO/UNICEF statement. Geneva: World Health Organization; 1989 (http://apps.who.int/iris/bitstream/10665/39679/1/9241561300.pdf, accessed 9 April 2020). Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide viii Breastfeeding history: All the relevant information about what has happened to a mother and baby, and how their present breastfeeding situation developed. Breastfeeding support: A group of mothers who help each other to breastfeed. Breast-milk substitute: Any food being marketed or otherwise represented as a partial or total replacement for breast milk, whether or not it is suitable for that purpose. Calories: Calories (or kilocalories) measure the energy available in food. Candida: Yeast that can infect the nipple, and the baby's mouth and bottom. Also known as “thrush”. Casein: Protein in milk, which forms curds. Cleft lip or palate: Abnormal division of the lip or palate. Closed questions: Questions that can be answered with “yes” or “no”. Cold compress: Cloths soaked in cold water to put on the breast. Colostrum: The special breast milk that women produce in the first few days after delivery; it is yellowish or clear in colour. Confidence: Believing in yourself and your ability to do things. Commercial infant formula: A breast-milk substitute formulated industrially, in accordance with applicable Codex Alimentarius standards, to satisfy the nutritional requirements of infants during the first months of life up to the introduction of complementary foods. Complementary feeding: The child receives both breast milk, or a breast-milk substitute, and solid (or semi-solid) food. Complementary food: Any food, whether manufactured or locally prepared, used as a complement to breast milk or to a breast-milk substitute. Counselling: A way of working with people so that you understand their feelings and help them to develop confidence and decide what to do. Cup-feeding: Feeding from an open cup without a lid, whatever is in the cup. Chemotherapy: The use of anti-cancer drugs to destroy cancer cells. Dehydration: Lack of water in the body. Ducts, milk ducts: Small tubes that take milk to the nipple. Dummy: An artificial nipple made of plastic for a baby to suck. Also known as a pacifier/soother. Early contact: A mother holding her baby during the first hour or two after delivery. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide ix Effective suckling: Suckling in a way that removes the milk efficiently from the breast. Empathize: Show that you understand how a person feels from her/his point of view. Engorgement: The breast is swollen with breast milk, blood and tissue fluid. Engorged breasts are often painful and oedematous and the milk does not flow well. Exclusive breastfeeding: An infant receives only breast milk and no other liquids or solids, not even water, with the exception of drops or syrups consisting of vitamins, mineral supplements or medicines. Expressed breast milk: Milk that has been removed from the breasts manually or by using a pump. Express: To squeeze or press out. Fissure: Break in the skin, sometimes called a “crack”. Flat nipple: A nipple that sticks out less than average. Foremilk: The watery breast milk that is produced early in a feed. Formula: Artificial milks for babies made out of a variety of products, including sugar, animal milks, soybean and vegetable oils. They are usually in powder form, to mix with water. Full breasts: Breasts that are full of milk, and hot, heavy and hard, but from which the milk flows. Gulp: Loud swallowing sounds due to swallowing a lot of fluid. Herpes simplex virus type 1 (HSV-1): A virus causing contagious sores, most often around the mouth or on the genitals. Hindmilk: The fat-rich breast milk that is produced later in a feed. HIV: Human immunodeficiency virus. HIV-negative: Refers to a person who has been tested for HIV with a negative result and who knows their result. HIV-positive: Refers to a person who has been tested for HIV, whose results have been confirmed and who knows, and/or their parents know that they tested positive. HIV testing and counselling: Testing for HIV status, preceded and followed by counselling. Testing should be voluntary and confidential, with fully informed consent. The expression means the same as the terms: “counselling and voluntary testing”, “voluntary counselling and testing”, and “voluntary and confidential counselling and testing”. Counselling is a process, not a one-off event: for the HIV-positive client it should include life planning, and, if the client is pregnant or has recently given birth, it should include infant-feeding considerations. Hormones: Chemical messengers in the body. Immune system: Those parts of the body and blood including lymph glands and white blood cells, that fight infection. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide x Immunity: A defense system that the body has to fight diseases. Ineffective suckling; Suckling in a way that removes milk from the breast inefficiently or not at all. Infective mastitis: Mastitis resulting from bacterial infection. Inhibit: To reduce or stop something. Inverted nipple: A nipple that goes in instead of sticking out, or that goes in when the mother tries to stretch it out. Jaundice: Yellow colour of eyes and skin. Judging words: Words that suggest that something is right or wrong, good or bad. Lactation: The process of producing breast milk. Lactation amenorrhea method: Using the period of amenorrhea after childbirth as a method for family planning. Lactose: The special sugar present in all milks. Lipase: Enzyme to digest fat. Low-birth-weight infant: A baby weighing less than 2.5 kg at birth. Mastitis: Inflammation of the breast (see also Infective mastitis and non-infective mastitis). Mature milk: The breast milk that is produced a few days after birth. Meconium stools: The initial black and tarry stool of a newborn. Micronutrients: Essential nutrients required by the body in small quantities (like vitamins and some minerals). Micronutrient supplements: Preparations of vitamins and minerals. Milk ejection: Milk flowing from the breast due to the oxytocin reflex, which is stimulated in response to the sight, touch or sound of the baby. Milk stasis: Milk staying in the breast and not flowing out. Milk expression: Removing milk from the breasts manually or by using a pump. Mixed feeding: Feeding both breast milk and other foods or liquids. Montgomery's glands: Small glands in the areola that secrete an oily liquid. “Nipple confusion”: A term sometimes used to describe the way babies who have fed from a bottle may find it difficult to suckle effectively from a breast. Nipple sucking: When a baby takes only the nipple into his/her mouth so that he/she cannot suckle effectively. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide xi Non-infective mastitis: Mastitis due to milk leaking out of the alveoli and back into the breast tissues with no bacterial infection. Non-verbal communication: Showing your attitude through your posture and expression. Nutrients: Substances the body needs that come from the diet. These are carbohydrates, proteins, fats, minerals and vitamins. Mother-support group: A community-based group of women providing support for optimal breastfeeding and complementary feeding. Open questions: Questions that can only be answered by giving information and not with just a “yes” or a “no”. Oxytocin: The hormone that makes the milk flow from the breast. Pacifier: Artificial nipple made of plastic for a baby to suck (Also called a dummy). Pneumonia: Infection of the lungs. Poorly protractile: Used to describe a nipple that is difficult to stretch out to form a “teat”. Positioning: How a mother holds her baby at her breast; the term usually refers to the position of the baby's whole body. Postnatal check: Routine visit to a health facility after a baby is born. Prelacteal feeds: Artificial feeds given before breastfeeding is established. Premature, preterm: Born before 37 weeks’ gestation. Prolactin: The hormone that makes the breasts produce milk. Protein: Nutrient necessary for growth and repair of the body tissues. Protractile: Used to describe a nipple that is easy to stretch out. Psychological: Mental and emotional. Reflect back: Repeat back what a person says to you, in a slightly different way. Reflex: An automatic response through the body's nervous system. Rejection of baby: The mother not wanting to care for her baby. Reluctant to feed at the breast: A baby having difficulty to suckle from his/her mother's breast. Replacement feeding: The process of feeding a child who is not receiving any breast milk with a diet that provides all the nutrients he/she needs until he/she is fully fed on family foods. During the first six months, this should be with a suitable breast-milk substitute. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide xii Responsive feeding: Feeding infants directly and assisting older children when they feed themselves, being sensitive to their hunger and satiety cues. Restricted breastfeeds: When the frequency or length of breastfeeds is limited in any way. Retained placenta: A small piece of the placenta remaining in the uterus after delivery. Rooming-in: A baby staying in the same room as their mother. Rooting: A baby searching for the breast with their mouth. Rooting reflex: A baby opening their mouth and turning to find the nipple. Scissor hold: Holding the breast between the index and middle fingers while the baby is feeding. Secrete: Produce a fluid in the body. Sensory impulses: Messages in nerves that are responsible for feeling. Sepsis: The body’s life-threatening response to infection that can lead to tissue damage, organ failure, and death Skin-to-skin contact: A mother holding her naked baby against her own skin. Sore nipples: Pain in the nipple and areola when the baby feeds. Sucking: Using negative pressure to take something into the mouth. Sucking reflex: A reflex that allows a baby to automatically suck something that touches his/her palate. Suckling: The action by which a baby removes milk from the breast. Supplements: Drinks or artificial feeds given in addition to breast milk. Support: Help. Sustaining: Continuing to breastfeed up to two years or beyond; helping breastfeeding mothers to continue to breastfeed. Swallowing reflex: A reflex whereby a baby automatically swallows when their mouth fills with fluid. Sympathize: Show that you feel sorry for a person, from your point of view. “Teat”: Stretched out breast tissue from which a baby suckles. Thrush: Infection caused by the yeast Candida. The infection occurs in the baby's mouth and forms white spots. Unrestricted feeding: See Responsive feeding. Warm compress: Cloths soaked in warm water to put on the breast. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 1 1. Course introduction 1.1 Course rationale The first few hours and days of a newborn baby’s life are a critical window for establishing breastfeeding and for providing mothers/parents/caregivers with the support they need to breastfeed successfully. Since 1991, the Baby- friendly Hospital Initiative (BFHI) has motivated facilities providing maternity and newborn-baby services worldwide to better support breastfeeding. It has been adopted by many countries and organizations. The BFHI aims to provide a health-care environment that supports parents' acquisition of skills necessary to exclusively breastfeed for six months, and to continue breastfeeding for two years or beyond. Breastfeeding and appropriate, safe and timely complementary feeding are fundamental to the health and development of children, and important for the health of their mothers. The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) have long recognized the need for the promotion of exclusive breastfeeding in the first six months of life and sustained breastfeeding for up to two years of age or beyond. A hospital that is designated as baby-friendly must fully implement the TEN STEPS TO SUCCESSFUL BREASTFEEDING. These are a summary of the recommendations of Protecting, promoting and supporting breastfeeding: the special role of maternity services2. This was a joint WHO/UNICEF statement, published in 1989. The “Ten Steps” became part of the Baby-friendly Hospital Initiative in 1991, and the updated version in 2009. They were then revised in 2018 and continue to be valid throughout the world as the basis of the BFHI. There is substantial evidence to show that the Ten Steps improves breastfeeding rates. This updated course is built upon the revised 2018 Ten Steps to successful breastfeeding, the latest version of the guidance for implementing the BFHI in facilities providing maternity and newborn services, and the World Health Organization (WHO) Implementation guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services – the revised Baby-friendly Hospital Initiative (BFHI) 3 . While the BFHI focuses on breastfeeding support, it also provides for integrated care to support all mothers including those who are not breastfeeding. In addition, the BFHI supports women living with HIV 4 . Many mothers have difficulty breastfeeding from the beginning, and health-care practices in many facilities hinder the process of establishing breastfeeding. However, even mothers who initiate breastfeeding satisfactorily often start supplements or stop breastfeeding within a few weeks of delivery. This may result in malnutrition, which is an increasing problem in many countries. It has been estimated that improved breastfeeding practices would prevent 823 000 annual deaths in children younger than five years of age 5 . Information on how to feed infants comes from multiple sources: family beliefs, community practices and information from health workers. Sometimes advertising and commercial promotion by food manufacturers is the source of information for many people, including families and health workers. It has often been difficult for health workers to discuss with families how best to feed their infants, owing to the confusing, and often conflicting information available. All health workers who care for women, children and families during the postnatal period and beyond have a key role to play in establishing and sustaining breastfeeding. Many health workers cannot fulfil this role effectively because they have received little more than basic training. Less time is assigned to communication and support skills for breastfeeding and infant feeding in the pre-service curricula of doctors, nurses, midwives or other professionals. 2 Protecting, promoting and supporting breastfeeding: the special role of maternity services. A joint WHO/UNICEF statement. Geneva: World Health Organization; 1989 (http://apps.who.int/iris/bitstream/10665/39679/1/9241561300.pdf, accessed 13 March 2020). 3 Implementation guidance: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services – the revised Baby-friendly Hospital Initiative. Geneva: World Health Organization; 1989 (https://apps.who.int/iris/bitstream/handle/10665/272943/9789241513807- eng.pdf?sequence=19&isAllowed=y, accessed 13 March 2020). 4 Guideline: updates on HIV and infant feeding: the duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV. World Health Organization and UNICEF; 2016. (http://apps.who.int/iris/bitstream/handle/10665/246260/9789241549707-eng.pdf?sequence=1, accessed 13 March 2020). 5 Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, Piwoz EG, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;387:491–504. doi:10.1016/S0140-6736(15)01044-2 Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 2 Hence, there is an urgent need in all countries to train those involved in breastfeeding in the immediate postnatal period in the skills needed to support and protect breastfeeding. The materials in this training course are designed to make it possible for trainers, even those with limited teaching experience on the subject, to conduct up-to-date and effective trainings. This course aims to give health workers basic counselling skills, so that they can help mothers and caregivers more effectively. “Counselling” is an extremely important component of this course material. Counselling is more than just listening. You listen to a new parent, try to understand how they feel, and learn from what they are telling you. You can then help them decide for themselves what is best, from various options or suggestions. This provides them with support and helps build confidence to carry out their own decisions. The course materials available from WHO/UNICEF include modules related to: ● counselling skills ● breastfeeding and infant feeding practices ● breastfeeding support ● critical management procedures. They are intended to be conducted in their entirety. However, the course is organized in such a way that the trainers can decide on the modules and sessions to cover, depending on the priorities and context of the country and the participants. The material could be thus used, for example, to hold a three-day course on the Ten Steps to Successful Breastfeeding, or courses on specific subjects. The course material can be used: 1. to complement existing courses 2. as part of the pre-service education of health workers. Disclaimer: This course material does NOT prepare people to have complete responsibility for the breastfeeding of newborn babies. It does not cover in depth topics on treatment, care and management of sick or low-birth-weight infants, or those living with HIV (including the use of antiretroviral drugs or antiretroviral therapy). The material covers only aspects specifically related to the Ten Steps to Successful Breastfeeding. Therefore, the participants should understand the need to refer to other health-care professionals when a situation arises for more advanced care. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 3 1.2 Course objectives After completing this course, participants will have the basic knowledge, skills and competence to: 1. protect, promote and support breastfeeding in the facilities where they work; and 2. understand the importance of the Ten Steps to Successful Breastfeeding and translate them into practice. Each session of the course has a set of learning objectives. While preparing to give a session, the trainer should make sure that they are clear about all learning objectives. 1.3 Target audience The target audience for this course are staff who have contact with pregnant women, mothers and their newborn infants. The staff may include: • doctors • midwives • nurses • health-care assistants • nutritionists • peer supporters • other staff. It is also targeted for use in pre-service training so that students are prepared with the knowledge and skills to support breastfeeding when they begin work. NOTE: Course participants are not expected to have any prior knowledge of breastfeeding. Some staff may not have a role in clinical care but would benefit from knowing more about why breastfeeding is important and how they can provide support. A 15–20 minute session provided later in this guide can be used as orientation to the course for non-clinical staff. It can also be used for new clinical staff who are on a waiting list to participate in the full course. The course can be translated into the national or local language of the country. After translation, the course should always be reviewed by one or more people qualified in lactation management in the country to ensure the accuracy of the information provided. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 4 1.4 Participant’s competencies: Training and follow-up This course is based on a set of competencies. These competencies define the learning expectations during the course and subsequent practice and follow-up in the workplace. To achieve competency, a person needs a certain amount of knowledge and proficiency in certain skills. The table on page 5 lists the competencies (column 1), the knowledge (column 2) and skills required (column 3) for each competency. Competencies 1. Knowledge: This competency will be taught during this course and is contained in the Participant’s manual for later referral and revision by participants. 2. Skills: This competency will also be taught during this course. However, there may not be time for each participant to become proficient in every skill. This will depend on their previous experience and on the opportunities available for practice. During the course, every participant should practise as many skills as possible, so that they know what to do when they return to their place of work. For example, if a participant has had the chance to successfully teach a mother to position and attach her baby to the breast, they will feel more confident in continuing to improve this skill when returning to work after the course. It is also essential that the trainers are competent in the communication and technical skills required. The groups should be small enough (one trainer to three to four participants) to ensure that the latter get as much practice as possible. Adequate planning is crucial to where the clinical practise sessions will take place, so there are enough mothers and newborns for all participants to have the opportunity to practise their skills (see section 2.3). If time is short, it is tempting to cut down on the time allocated to the clinical practise sessions. However, it is important to remember that these slots represent the only time that participants will have to practise their skills, so it is encouraged to prioritize the clinical practice sessions. Most people find that they acquire the “knowledge” part of the competency more quickly than the “skills” part. Participants will gain knowledge, but knowledge on its own does not make someone competent at carrying out a task. For example, you may be able to list the steps of how to teach a mother to cup feed her baby. But, if you have never practised this skill, you may not be competent at actually carrying it out. While participants in this course may not learn all the skills listed, they should all have a chance to practise them at least once during the course. This will help the participants understand how they can continue to practise them when they return to their place of work. The competencies are arranged according to area/session and in a certain order. The competencies at the beginning of table 1 below are most commonly used and are those on which later competencies will depend. For example, the competency USE LISTENING AND LEARNING SKILLS TO COUNSEL A MOTHER/PARENT/CAREGIVER is used in many of the other competencies. Take time to read through the table before the course. The theory (“knowledge”) required is found in the Trainer’s guide and will be covered in the lecture sessions of the participant's course. The skills are practised in the classroom practical sessions, the exercises and the clinical practice sessions in clinical facilities. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 5 TABLE 1. COURSE COMPETENCIES Competency Knowledge Skills Session Counselling C1. Use listening and learning skills whenever engaging in a conversation with a mother . List the LISTENING AND LEARNING SKILLS . Give an example of each skill . Use the LISTENING AND LEARNING SKILLS when counselling a mother or caregiver on feeding an infant . S3 C2. Use skills for building confidence and giving support whenever engaging in a conversation with a mother . List the SKILLS FOR BUILDING CONFIDENCE AND GIVING SUPPORT . Give an example of each skill . Use the SKILLS FOR BUILDING CONFIDENCE AND GIVING SUPPORT when counselling a mother or caregiver on feeding an infant . S4 Breastfeeding BF1. Engage in antenatal conversation about breastfeeding . Explain why exclusive breastfeeding is important for the first six months . Explain the importance of skin-to-skin contact immediately after delivery and the initiation of breastfeeding within one hour . List the special properties of colostrum and reasons why it is important . Explain good positioning and attachment . List the risks of not breastfeeding . Use counselling skills with a pregnant woman to listen to her questions and concerns about breastfeeding, and discuss how you may be able to help her . Reinforce her previous knowledge and give her additional information according to her needs including: . advantages of exclusive breastfeeding . the importance of skin-to-skin contact immediately after delivery . how to initiate and establish breastfeeding after delivery . the importance of colostrum . the optimal breastfeeding patterns . responsive feeding and feeding cues . rooming-in . health-care practices and the help that she will receive after delivery . Demonstrate good positioning and how to attach baby to the breast and ask her to practice with a doll . Apply competencies C1, C2 and parts of BF4 . S17, S18 Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 6 Competency Knowledge Skills Session BF2. Implement immediate and uninterrupted skin-to-skin . Explain the importance of early contact after delivery and of the baby receiving colostrum . Describe the procedure of putting the baby in skin-to- skin contact immediately after delivery . Help a mother to initiate skin-to- skin contact and breastfeeding . S6 BF3. Facilitate breastfeeding within the first hour, according to cues . Describe how a baby moves to the breast and attaches by itself, and how to help the baby if needed . Describe how health-care practices affect initiation of breastfeeding . Help a mother to initiate skin-to- skin contact and breastfeeding . Apply competencies C1, C2, BF5 . S6, S7 BF4. Discuss with a mother how breastfeeding works . Describe the physiology of breast-milk production and flow . Explain the physiology of lactation hormones . Describe responsive feeding and implications for the frequency and duration of breastfeeds . Describe the importance of exclusive breastfeeding for six months and continued breastfeeding for up to two years and beyond . Explain to a mother the onset and stages of milk production including about colostrum and “coming in” of mature milk . Explain to a mother about the optimal pattern of breastfeeding and responsive feeding, at different stages . Talk to women individually or in groups about optimal infant feeding (includes referring a mother to community resources) . S2, S5, S14, S16 BF5. Assist mother getting her baby to latch . Describe the relevant anatomy and physiology of the breast and suckling action of the baby . Describe effective and ineffective suckling . Describe the difference between good and poor attachment of a baby at the breast . Explain the FOUR KEY POINTS OF ATTACHMENT . Explain the FOUR KEY POINTS OF POSITIONING . Explain the main positions for the mother: sitting, lying down, side-lying . Explain different ways to hold the baby: underarm, across, and others . Describe how a mother should support her breast for feeding . Recognize correct positioning, according to the FOUR KEY POINTS OF POSITIONING . Assess a breastfeed using the JOB AID: BREASTFEEDING OBSERVATION . Demonstrate how to assess a breastfeed . Identify a mother who may need help . Show a mother how to hold and position her baby, by demonstrating with a doll . Help a mother to position her baby using the four key points, in different positions . Show a mother how to support her breast for feeding . Help a mother to find a comfortable position for breastfeeding . Help a mother to get her baby to attach to the breast once they are well positioned . Help the mother to recognize whether the baby is well attached or not . S5, S8, S9, S10 Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 7 Competency Knowledge Skills Session BF6. Help a mother respond to feeding cues . Explain about a baby’s feeding cues . Describe how the use of a feeding bottle, teat or pacifier can prevent the mother from recognizing feeding cues of her baby . Help a mother recognize her baby’s feeding cues . Help a mother feed her baby baby responding to the feeding cues . S7, S12, S13, S17, S19 BF7. Help a mother manage milk expression . Explain why expressing breast milk is useful for mothers or babies who have difficulty feeding at the breast, or who are separated from each other . Describe the relevant anatomy of the breast and physiology of lactation . List the steps of expressing breast milk by hand . Explain how to stimulate the oxytocin reflex . Demonstrate to a mother the steps of expressing breast milk by hand . Apply competencies C1 and C2, and teach a mother how to express breast milk by hand . S13 BF8. Help a mother to breastfeed a low- birth-weight or sick baby . Describe alternative methods of feeding . Explain how to feed a low- birth weight or sick baby by cup . Explain how to introduce a LBW baby gradually to the breast, using the same principles of positioning and attachment . Help a mother or caregiver to cup- feed the low-birth-weight baby. . Apply competencies, especially BF7 and BF10, to manage these infants appropriately . Help a mother to introduce her baby gradually to her breast . S7, S9, S13 BF9. Help a mother when baby needs fluids other than breastmilk . Explain the possible medical indications for supplementation . Explain how to choose an appropriate supplement . Describe the safe preparation of giving additional fluids other than mother’s own milk . List the risks of using a feeding bottle, teat or pacifier . Explain to mother the risks of not breastfeeding exclusively using competencies C1 and C2 . Help a mother understand the importance of avoiding any food or fluids other than breast milk, unless medically indicated . Help support a mother whose baby needs fluids other than breastmilk . S13, S14 BF10. Help a mother who is not feeding her baby directly at the breast . List the advantages of cup- feeding . Describe how to cup feed a baby . List the risks of using a feeding bottle, teat or pacifier . Teach a mother how to cup feed her baby safely . Practise with a mother how to cup feed her baby safely . S13, S14, S17, S18 Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 8 Competency Knowledge Skills Session BF11. Help a mother prevent or resolve difficulties with breastfeeding . Explain normal newborn feeding behaviour and intake. . List the signs and symptoms that indicate a newborn may not be getting enough milk . Explain the common reasons why a newborn may not get enough breast milk . Explain how to prevent and manage milk insufficiency in newborns . List different reasons why babies cry in the immediate postnatal period . Describe the management of a crying baby in the immediate postnatal period List the causes of why a baby may be reluctant to feed at the breast Explain the difference between flat and inverted nipples and about protractility and how to manage flat and inverted nipples Explain the reasons why breasts may become engorged and how to manage breast engorgement List causes of sore or cracked nipples List the causes of a blocked milk duct Explain how to treat a blocked milk duct List the causes of mastitis Explain how to manage mastitis, including indications for antibiotic treatment and referral Explain what is different when treating mastitis in a mother living with HIV . Decide whether a newborn is getting enough breast milk or not. . Explain the cause of the difficulty to the mother . Help a mother whose baby is not getting enough breast milk. . Help a mother who thinks her baby is not getting enough milk. Help a mother whose aby is reluctant to feed at the breast Recognize flat and inverted nipples Demonstrate how to use the syringe method for the treatment of inverted nipples Recognize engorged breasts Recognize sore and cracked nipples Recognize mastitis and refer to the appropriate level of care if necessary Manage a blocked duct appropriately . Apply competencies C1 and C2 and BF4 to BF7, and BF10 to overcome the difficulty, including explaining the cause of the difficulty to the mother Apply competencies BF7 and BF10 to maintain breast- milk production and to feed the baby meanwhile . S11, S15, S16, S12, S13 Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 9 Competency Knowledge Skills Session BF12. Ensure seamless transition after discharge . Explain how to prepare a mother for discharge . Explain the importance of follow-up care for a new mother and her baby . Describe the available community resources to support breastfeeding . Provide information to a mother about how to get continuing support and help after discharge . Help a mother with support to ensure breastfeeding continues longer after discharge . Help a mother recognize signs and symptoms that indicate a newborn may not be getting enough milk and to seek medical help when necessary . mothers are given information about how to get continuing support and help after discharge . S16, S19 Policies and programmes related to breastfeeding PP1. Implement the International code of marketing of breast-milk substitutes in a health facility . Describe how commercial promotion of breast-milk substitutes undermines good breastfeeding practices . List the major provisions of the International Code of Marketing of Breast-milk Substitutes and subsequent World Health Assembly resolutions (the Code) . Describe health-workers’ responsibilities for complying with the Code . Recognize common violations of the Code . Indicate appropriate actions to take when violations are identified in the health facility . S20, S21 PP2. Explain a facility’s infant feeding policies and monitoring systems . Describe quality improvement in a facility, as part of the Ten Steps . Explain the importance of infant feeding policies . Explain the global standards from each of the TEN STEPS TO SUCCESSFUL BREASTFEEDING . Outline the health-care practices summarized by the TEN STEPS TO SUCCESSFUL BREASTFEEDING . Routinely administer client satisfaction surveys or exit interviews to each mother before being discharged if required as part of health-facility monitoring . Record the care of each mother/baby pair (e.g. early initiation, rooming in), and also analyse the data over a period of time if necessary for quality improvement processes . Collect and record data requested by the facility, to ensure standard of care in line with infant feeding policy, which can be evaluated and monitored . S21 Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 10 1.5 Course structure The course is divided into various modules and sessions. Depending on the modules and sessions selected, the course will take different times. It can be conducted over three days or can be customized in other ways. The sessions use a variety of teaching methods. These include lectures, demonstrations and small group work. The classroom-based practical exercises, and clinical practice sessions are held in wards and clinical facilities. 1.5.1 Session order The proposed session order can be customized based on the goals of the specific course. The main requirement is for the sessions to prepare participants for a particular practical or clinical practice session to be conducted before the practical. 1.6 Course materials 1.6.1 Director’s guide The Director’s guide describes the director’s role during the course. It contains all the information the course director needs to plan and prepare for a course, to decide which modules and sessions will be included in the training, and to select trainers and participants. This process should begin several months before the actual training. It contains lists of the materials and equipment needed, timetable samples, and copies of the forms to be photocopied before a course 1.6.2 Trainer's guide The Trainer's guide is the trainer's most essential tool. It is recommended that trainers use it at all times and add notes to it as they work. These notes will help trainers in future courses. It contains what the trainer needs in order to lead participants through the course. The guide contains the required information, detailed instructions on how to conduct each session, and exercises for participants with answers. To be used during practical sessions of the course, the summary sheets, forms, checklists and stories are included. 1.6.3 Slides (PowerPoint) Many sessions use slides. The director should inform trainers which ones to use. It is important that trainers are familiar with the audio-visual (AV) equipment beforehand. All slides are shown in the Trainer’s guide, so that trainers can make sure they understand the information, pictures or graphs before the sessions. 1.6.4 Participant's manual A Participant's manual should be provided for each participant, using the sessions selected. This contains summaries of information, copies of worksheets, checklists for the clinical practice sessions and exercises that they will do during the course (without answers). This manual can be used for reference after the course, so it is not essential for participants to take detailed notes. 1.6.5 Forms and checklists Loose copies of the forms and checklists needed for practical and clinical practice sessions and counselling exercises are provided. These are listed below. For both general use for clinical practice sessions • SKILLS CHECKLIST: LISTENING AND LEARNING • CHECKLIST: COUNSELLING SKILLS (includes listening and learning skills, and skills for building confidence and giving support) • CHECKLIST: CLINICAL PRACTICE DISCUSSION (for trainers only) • COMPETENCY PROGRESS FORM Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 11 Job aids and reference tools • JOB AID: BIRTH PRACTICES CHECKLIST • JOB AID: BREASTFEEDING SESSION OBSERVATION • JOB AID: ANTENATAL CHECKLIST General assessment and follow-up • ASSESSING AND CHANGING PRACTICES FORM (for optional activity) • LOG OF SKILLS PRACTISED (for participants only) • DIFFICULTIES EXPERIENCED (for participants only) 1.6.6 Answer sheets These are provided separately and give answers to all the exercises. They should be given to the participants after they have completed the exercises. 1.6.7 Updates WHO and UNICEF websites: Periodic updates on this course will be available on the WHO and UNICEF websites. Please consult these sites when preparing a course. 1.6.8 Training aids Trainers will need the following aids. • Flipchart • Blackboard and chalk • White board and markers • Masking tape • Life-size baby doll and model breast (for each small working group of three or four participants) NOTE: If dolls and breasts are not available, please follow the following instructions for the course. TABLE 2. HOW TO MAKE A MODEL DOLL • Find any large fruit or vegetable, a towel or other strong thick cloth, and some rubber bands or string. • Put the fruit or vegetable in the middle of the cloth and tie the cloth around it to form the baby's “neck” and “head”. • Bunch the free part of the cloth together to form the baby's legs and arms and tie them into shape. • If the cloth is rather thin, you may like to stuff some other cloth inside to give the doll more of a “body”. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 12 TABLE 3. HOW TO MAKE A MODEL BREAST • Use a pair of near skin-coloured socks, or stockings, or an old sweater or T-shirt. • Make the cloth into a round bag shape, and stuff it with other cloth or foam rubber to make it breast shaped. • Stitch a “purse string” around a circle in the middle of the breast to make a nipple. • Stuff the nipple with foam or cotton. • Colour the areola with a felt pen. You can also push the nipple in to make an “inverted” nipple. • If you wish to show the inside structure of the breast with the larger ducts, make the breast with two layers, for example with two socks. • Sew the nipple in the outer layer and draw the large ducts and ducts on the inside layer beneath the nipple. • You can remove the outer layer with the nipple to reveal the inside structure. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 13 1.7 Reference materials As a director, you may wish to obtain the following reference materials to answer questions and provide additional information. Breastfeeding ● Bu’Lock F, Woolridge MW, Baum JD. Development of co-ordination of sucking, swallowing and breathing: ultrasound study of term and preterm infants. Dev Med Child Neurol. 1990; 32: 669–78. ● Butte N, Lopez-Alarcon M, Garza C. Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life. Geneva: World Health Organization; 2002 (http://apps.who.int/iris/bitstream/10665/42519/1/9241562110.pdf?ua=1, accessed 24 March 2020). ● Campbell SH, Lauwers J, Mannel R, Spencer B. Core curriculum for interdisciplinary lactation care. LEEARC. Burlington (MA): Jones & Bartlett; 2019. ● DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity-care practices on breastfeeding. Pediatrics. 2008;122(Suppl. 2):S43–9. doi:10.1542/peds.2008-1315e ● Eglash A, Simon L, The Academy of Breastfeeding Medicine. ABM Clinical Protocol #8: Human milk storage information for home use for full-term infants, revised 2017. Breastfeed Med. 2017; 2:390–95. doi: 10.1089/bfm.2017.29047.aje ● Foster JP, Psaila K, Patterson T. Non-nutritive sucking for increasing physiologic stability and nutrition in preterm infants. Cochrane Database Syst Rev. 2016;(10):CD001071. doi:10.1002/14651858.CD001071.pub3 ● Greene Z, O’Donnell CP, Walshe M. Oral stimulation for promoting oral feeding in preterm infants. Cochrane Database Syst Rev. 2016;(9). doi:10.1002/14651858.CD009720.pub2 ● Jaafar SH, Ho JJ, Jahanfar S, Angolkar M. Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding. Cochrane Database Syst Rev. 2016(8):CD007202. doi:10.1002/14651858.CD007202.pub4 ● Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding, A systematic review. Geneva: World Health Organization; 2001 (http://apps.who.int/iris/bitstream/10665/67208/1/WHO_NHD_01.08.pdf?ua=1, accessed 10 April 2020). ● Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC et al. The Lancet Breastfeeding Series Group. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;387:491–504. doi:10.1016/S0140- 6736(15)01044-2 ● Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/infantfeeding/9241561300/en/, accessed 24 March 2020, accessed 10 April 2020). ● Long-term effects of breastfeeding: a systematic review. Geneva: World Health Organization; 2013 (http://apps.who.int/iris/bitstream/10665/79198/1/9789241505307_eng.pdf?ua=1, accessed 24 March 2020). ● Short-term effects of breastfeeding: a systematic review of the benefits of breastfeeding on diarrhoea and pneumonia mortality. Geneva: World Health Organization; 2013 (http://apps.who.int/iris/bitstream/10665/95585/1/9789241506120_eng.pdf?ua=1, accessed 24 March 2020). ● Community-based strategies for breastfeeding promotion and support in developing countries. Geneva: World Health Organization; 2003 (http://apps.who.int/iris/bitstream/10665/42859/1/9241591218.pdf, accessed 24 March 2020). ● Statement on the effect of breastfeeding on mortality of HIV-infected women. Geneva: World Health Organization; 2001 (http://ibfan.org/docs/Effect-of-Breastfeeding-on-Mortality-among-HIV-Infected-Women-WHO-statement.pdf, accessed 24 March 2020). ● The optimal duration of exclusive breastfeeding, Report of an expert consultation. Geneva, Switzerland, 28–30 March 2001. Geneva: World Health Organization; 2001 (WHO/FCH/CAH/01.24; http://apps.who.int/iris/bitstream/10665/67219/1/WHO_NHD_01.09.pdf?ua=1, accessed 24 March 2020). ● Mastitis. Causes and management. Geneva: World Health Organization; 2000 (WHO/FCH/CAH/00.13; http://www.who.int/maternal_child_adolescent/documents/fch_cah_00_13/en/, accessed 24 March 2020). ● Breastfeeding and maternal tuberculosis. Geneva: World Health Organization; 1998 (http://www.who.int/maternal_child_adolescent/documents/breastfeeding_maternal_tb/en/, accessed 24 March 2020). ● Evidence for the ten steps to successful breastfeeding. Geneva: World Health Organization; 1998 (WHO/ CHD/98.9; http://apps.who.int/iris/bitstream/10665/43633/1/9241591544_eng.pdf, accessed 24 March 2020). Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 14 ● Hepatitis B and breastfeeding. Update no. 22. Geneva: World Health Organization; 1996 (http://www.who.int/maternal_child_adolescent/documents/pdfs/hepatitis_b_and_breastfeeding.pdf?ua=1, accessed 24 March 2020). ● WHO, UNICEF. Breastfeeding advocacy initiative: for the best start in life. Geneva: World Health Organization; 2015 (http://www.who.int/nutrition/publications/infantfeeding/breastfeeding_advocacy_initiative/en/, accessed 24 March 2020). ● WHO, UNICEF. Global Nutrition Targets 2015. Breastfeeding policy brief. Geneva: World Health Organization; 2014 (WHO/NMH/NHD/14.7; http://apps.who.int/iris/bitstream/10665/149022/1/WHO_NMH_NHD_14.7_eng.pdf?ua=1, accessed 24 March 2020). ● WHO, UNICEF. Breastfeeding and maternal medication: recommendations for drugs in the eleventh WHO model list of essential drugs. Geneva: World Health Organization; 2002 (http://apps.who.int/iris/bitstream/10665/62435/1/55732.pdf, accessed 24 March 2020). ● Yamauchi Y, Yamanouchi I. Breast-feeding frequency during the first 24 hours after birth in full-term neonates. Pediatrics. 1990;86:171–5. Breast-milk substitutes ● Kellams A, Harrel C, Omage S, Gregory C, Rosen-Carole C, Academy of Breastfeeding Medicine. ABM Clinical Protocol #3: Supplementary feedings in the healthy term breastfed neonate, revised 2017. Breastfeed Med. 2017;12:188–98. doi:10.1089/bfm.2017.29038.ajk ● Maternal, infant and young child feeding. Guidance on ending the inappropriate promotion of foods for infants and young children. In: Sixty-ninth World Health Assembly, Geneva, 23–28 May 2016. Provisional agenda item 12.1. Geneva: World Health Organization; 2016. ● Country implementation of the International Code of Marketing of Breast-milk Substitutes: status report 2011. Geneva: World Health Organization; 2013. http://apps.who.int/iris/bitstream/10665/85621/1/9789241505987_eng.pdf?ua=1, accessed 24 March 2020). ● Acceptable medical reasons for use of breast-milk substitutes. Geneva: World Health Organization; 2009 (http://www.who.int/maternal_child_adolescent/documents/WHO_FCH_CAH_09.01/en/, accessed 24 March 2020). ● The international code of marketing of breast-milk substitutes: frequently asked questions (updated version 2008). Geneva: World Health Organization; 2008 (http://www.who.int/nutrition/publications/infantfeeding/9789241594295/en/, accessed 24 March 2020). ● International code of marketing of breast-milk substitutes. Geneva: World Health Organization; 1981 (http://apps.who.int/iris/bitstream/10665/40382/1/9241541601.pdf, accessed 24 March 2020). ● WHO, UNICEF, IBFAN. Marketing of breast-milk substitutes: national implementation of the international code: status report 2016. Geneva: World Health Organization; 2016 (http://www.who.int/nutrition/publications/infantfeeding/code_report2016/en/, accessed 24 March 2020). HIV ● Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. 2016 update. Geneva: World Health Organization; 2016 (http://www.who.int/hiv/pub/guidelines/keypopulations-2016/en/, accessed 24 March 2020). ● Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Recommendations for a public health approach, 2nd ed. Geneva: World Health Organization; 2016 (http://www.who.int/hiv/pub/arv/arv-2016/en/, accessed 24 March 2020). ● Counselling and voluntary HIV testing for pregnant women in high HIV prevalence countries. Elements and issues. Geneva: Joint United Nations Programme on HIV/AIDS; 2001 (UNAIDS/99.40E; http://www.hivpolicy.org/Library/HPP000138, accessed 24 March 2020). ● WHO, UNICEF. Guideline: updates on HIV and infant feeding: the duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV. Geneva: World Health Organization; 2016 (http://apps.who.int/iris/bitstream/10665/246260/1/9789241549707-eng.pdf?ua=1, accessed 24 March 2020). Infant and young child feeding ● Comprehensive implementation plan on maternal, infant and young child nutrition. Geneva: World Health Organization; 2014 (WHO/NMH/NHD/14.1; http://apps.who.int/iris/bitstream/10665/113048/1/WHO_NMH_NHD_14.1_eng.pdf?ua=1, accessed 24 March 2020). ● WHO, UNICEF. Global strategy for infant and young child feeding. Geneva: World Health Organization; 2003 (http://www.who.int/nutrition/publications/infantfeeding/9241562218/en/, accessed 24 March 2020). Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 15 ● WHO, UNICEF. Implementing the Global Strategy for Infant and Young Child Feeding. Geneva 3–5 February 2003. Meeting report. Geneva: World Health Organization; 2003 (http://apps.who.int/iris/bitstream/10665/42858/1/924159120X.pdf?ua=1, accessed 24 March 2020). Maternal and newborn care ● Kuyper E, Vitta B, Dewey K. Implications of caesarean delivery for breastfeeding outcomes and strategies to support breastfeeding. Washington (DC): Alive & Thrive Insight; 2014 (A&T Technical Brief Issue 8, February 2014; https://www.aliveandthrive.org/wp-content/uploads/2018/07/Insight-Issue-8-Cesarean-Delivery-English.pdf, accessed 24 March 2020). ● McFadden A, Gavine A, Renfrew MJ, Wade A, Buchanan P, Taylor JL et al. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Syst Rev. 2017;2:CD001141. doi:10.1002/14651858. CD001141.pub5 ● Meier PP, Furman LM, Degenhardt M. Increased lactation risk for late preterm infants and mothers: evidence and management strategies to protect breastfeeding. J Midwifery Women’s Health. 2007;52:579–87 (http://www.breastnbabylactation.com/pdf/paula_preterm.pdf, accessed 10 April 2020). ● Munn AC, Newman SD, Mueller M, Phillips SM, Taylor SN. The impact in the United States of the Baby-Friendly Hospital Initiative on early infant health and breastfeeding outcomes. Breastfeed Med. 2016;11:222–30. doi:0.1089/bfm.2015.0135 ● Nyqvist KH, Sjoden PO, Ewald U. The development of preterm infants’ breastfeeding behavior. Early Hum Dev. 1999;55:247–64. ● Pérez-Escamilla R, Martinez JL, Segura-Pérez S. Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review. Maternal Child Nutr. 2016;12):402–17. doi:10.1111/mcn.12294 ● Saadeh RJ. The Baby-Friendly Hospital Initiative (BFHI) 20 years on: facts, progress and the way forward. J Hum Lact. 2012;3:272−5. doi:10.1177/0890334412446690 ● Smith LJ, Kroeger M. Impact of birthing practices on breastfeeding, 2nd ed. Sudbury (MA): Jones and Bartlett; 2010. ● Stevens J, Schmied V, Burns E, Dahlen H. Immediate or early skin-to-skin contact after a Caesarean section: a review of the literature. Maternal Child Nutr. 2014;10:456–73. doi:10.1111/mcn.12128 ● WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018 (http://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf, accessed 24 March 2020). ● Quality, equity, dignity. A network for improving quality of care for maternal, newborn and child health. Quality of care; 2017 (http://www.who.int/pmnch/media/news/2017/improving-qualitycare-achieve-sdgtargets.pdf, accessed 24 March 2020). ● Kangaroo mother care: a practical guide. Geneva: World Health Organization; 2003 (http://www.who.int/maternal_child_adolescent/documents/9241590351/en/, accessed 24 March 2020). ● Hypoglycaemia of the newborn. Review of the literature. Geneva: World Health Organization; 1997 (WHO/CHD/97.1; http://apps.who.int/iris/bitstream/10665/63362/1/WHO_CHD_97.1.pdf, accessed 24 March 2020) ● WHO, UNICEF. Baby-Friendly Hospital Initiative. Revised, expanded and updated for integrated care. Geneva: World Health Organization; 2009 (http://www.who.int/nutrition/publications/infantfeeding/bfhi_trainingcourse/en/, accessed 24 March 2020). ● WHO, UNFPA, UNICEF. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, 3rd ed. Geneva: World Health Organization; 2015 (http://www.who.int/maternal_child_adolescent/documents/imca-essential-practice-guide/en/, accessed 24 March 2020). Safe preparation of supplementary feeding: ● Adams M, Motarjemi, Y. Basic food safety for health workers. Geneva: World Health Organization; 1999 (WHO/SDE/PHE/FOS/99.1; http://apps.who.int/iris/bitstream/10665/65992/1/WHO_SDE_PHE_FOS_99.1.pdf?ua=1, accessed 24 March 2020). ● Basic principles for the preparation of safe food for infants and young children. Geneva: World Health Organization; 1996 (WHO/FNU/FOS/96.6 http://apps.who.int/iris/bitstream/10665/67833/1/WHO_FNU_FOS_96.6.pdf, accessed 24 March 2020). ● FAO, WHO. Safe preparation, storage and handling of powdered infant formula. Guidelines. Geneva: World Health Organization; 2007 (http://www.who.int/foodsafety/publications/powdered-infant-formula/en/, accessed 24 March 2020). 1.8 Clerical and logistical support Make sure clerical and support staff will be willing to help and be available at the site to make photocopies and to prepare the course space. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 16 1.9 Funds required Examples of course costs: • participants’ travel and per diem expenses, if required • trainers’ travel and per diem and special compensation, if required • payment for clerical support staff • travel to and from the health facility, if necessary • stationery, equipment and items for the demonstrations • refreshments • accommodation and meals, if not covered by per diem expenses • photocopying costs. Make sure there are enough funds to cover the above costs. If trainers and/or participants need to arrive the day before the course starts or remain until the day after the course finishes, ensure there are sufficient funds to cover accommodation and meals for these nights. 1.10 Ceremonies: Opening and closing You may wish to have an opening and closing ceremony for the participants. This may include an invited speaker to open the course, close the course and present certificates to the participants and any new trainers. This is a great way to involve representatives from the government and key institutions to increase the awareness of the training and to acknowledge or obtain their support for BFHI activities. Send an invitation with a short description of the course and the participants. Make it clear whether or not you want the invitee to make a speech. Also, note the exact time available. Send them relevant information for them to mention. For example, local breastfeeding data, local or national Baby Friendly hospital initiative data, the purpose of this course and global initiatives to support breastfeeding. Offer to provide additional information, if required. If possible before the course, contact personally the individuals who accept the invitation to ensure they fully understand the context for their speech. The time for opening and closing ceremonies has not been included in the course session times. Please add it to your specific course timetable. It is important that your course schedule does not get disturbed by lengthy speeches, particularly on the first day. For a residential course, you may find it more convenient to hold the opening ceremony on the evening before the course starts once all the participants have arrived. This provides a good opportunity to welcome everyone, go over the arrangements and give out course materials. It also means that you can start directly with Session 1 the following morning. 1.11 Course director’s role The course director has overall responsibility for the planning and preparation of the course and ensuring the course runs smoothly. This includes: • ensuring the pre-planning is carried out • preparing the trainers • coordinating and assisting trainers during the course • ensuring the course runs according to the planned timetable • introducing the course • conducting the closing session • conducting the course evaluation • discussing follow-up activities. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 17 The course director should have experience in participating in this course as a trainer and have strong planning skills. They will need to allocate some time to the pre-course planning and working with a local organizer in the months preceding the course. If not based in the area, the course director should arrive at the course site one to two days before the course to ensure arrangements are in place and should be present throughout the entire course. At times, the course director may not be based in the area where the course will take place. In this case, a local organizer or contact person may arrange the facilities. The course director is responsible for ensuring the local organizer understands the tasks and for confirming the tasks are complete. Checklists and other relevant pages of this guide may be copied for the local organizer. NOTE: The course director does not normally conduct sessions. However, in sessions that involve a lot of group work, they can assist the trainer assigned to the session with their group of three or four participants. The course director should not have sole responsibility for a group of participants. It is also important that the course director is free from conflict of interest created by companies that market foods for infants and young children. Arrangements: Course location For a successful course, you need to arrange: • classroom space for the course and classroom space for training the trainers • lodgings and meals for the trainers and participants • sites for the clinical practice sessions. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 18 2. Arrangements: Course location 2.1 Classroom facilities The classroom facilities should include: • one large room available for seating all facilitators, participants and visitors • additional table space to lay out the materials used during the course. Note: The classrooms should be in a place where the participants are not disturbed by too much background noise and should have adequate lighting and ventilation. 2.2 Accommodation and meals For a residential course, it is necessary to arrange suitable accommodation near the classroom and the health facility. Unsatisfactory accommodation can hinder participants' learning. If necessary, adequate transportation should be available from the accommodation to the classroom and to the facilities for the clinical practice sessions. If participants are travelling long distances, ensure that the budget will cover the accommodation for the night before and the last night of the course. Arrangements also need to be made for meals. These should include midday meals and refreshments, such as coffee and tea, near the classrooms. 2.3 Sites for clinical practical sessions The clinical practice and practical sessions should take place at the following site: • postnatal ward • a facility providing maternity and newborn services. NOTE: There should be enough breastfeeding mothers and babies for each participant to talk to at least one mother. If the facility is not large enough to provide enough mothers and newborns, you may use another nearby facility and send some of the small groups of four participants to each site. As discussed earlier, for participants to become competent in the necessary skills, it is important for them to practise, under supervision, as many skills as possible during the course. Therefore, there should be enough mother/newborn babies for each of the clinical practice sessions, particularly if they are on consecutive days. If the facility is not close to the classrooms, you need to make transport arrangements to ensure that the participants can commute between the classrooms and the health facility in the most efficient way, with minimal loss of time. Transport time may need to be included in the timetable for the sessions. Note: Each clinical practice session takes approximately two hours. High priority: The course timetable cannot be planned until the times of the clinical practice sessions are decided. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 19 2.3.1 Health facility visit Visit one or more possible facilities to find out whether they are appropriate and to talk to the staff.  Talk to the director of the facility  Explain what the training consists of, what your needs are, and what you want to do.  Ask whether they would be willing for the training to take place in the facility, and for their guidance on where different activities could take place.  If the director agrees, visit the postpartum unit or area providing maternity and newborn services.  Check the approximate number of mother and newborns you could expect to see on an average day. For about 20 participants, approximately 10–20 mother/newborns should be available.  Ask what times of the day are most suitable for holding the clinical practice sessions. This depends on when mothers and children are likely to be available and times convenient for the facility’s routine.  Talk to the staff and try to find out whether they are interested in helping with the course. Would they be willing to share their experiences with the course participants?  Identify spaces or rooms near each clinic area where trainers and participants can have discussions out of mothers’ hearing.  If the facility is adequate and the staff are interested and willing to help, arrange to make another visit nearer the time of the course to meet with the staff and prepare them. 2.3.2 Prepare the facility staff It is important to prepare the health facility to help during clinical practice sessions. If necessary, arrange an orientation session to explain the purpose of the course more clearly. At the meeting, explain about the course and that you need their help to: 1. prepare mothers/parents/caregivers 2. ask their permission before the participants arrive 3. introduce participants to mothers/parents/caregivers. 4. have a responsible member of the facility staff available while the training team is there, in case a mother/newborn needs a specific intervention – interventions will only take place with the permission and knowledge of facility staff which will also enable staff to provide follow-up for the newborn. Explain when you would like to bring participants to the facility for the different sessions. Check that the timings are convenient, and mothers are expected to be available at that time. Leave some copies of reference materials for staff to read. An example of an information sheet is provided below. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 20 TABLE 4: EXAMPLE OF AN INFORMATION SHEET FOR A CLINICAL PRACTICE SITE (TO BE ADAPTED ACCORDING TO THE CONTENT AND CONTEXT OF THE COURSE) Baby-Friendly Hospital Initiative: A training course for maternity staff Course objectives After completing this course, participants will be able to will have the knowledge, skills and competence to protect, promote and support breastfeeding in the facilities where they work and understand the importance of the Ten Steps to Successful Breastfeeding and translate them into practice in their own place of work. On completion of the course participants should be able to assess breastfeeding mothers and their newborn babies, provide assistance to help a mother and her baby with breastfeeding, and identify and manage common breastfeeding difficulties. Participants will also be able to talk with mothers in the antenatal and immediate postpartum periods and support them in their infant feeding decisions. Your help We would like your assistance with the clinical practice sessions of this course. During these sessions, participants practise counselling skills with mothers. In one clinical practice session, participants talk with pregnant women to help prepare them for infant feeding. In the other clinical practice sessions in the postpartum unit, participants talk with mothers and provide breastfeeding counselling and support. Your help is needed to prepare mothers to ask their permission before the participants arrive and to introduce participants to mothers to whom they can talk. If a mother/newborn needs a specific intervention, this will only take place with the permission and knowledge of health-facility staff. This will also enable staff to provide follow-up for the newborn or mother. The visit to your facility would be on: (date) …………… from (time) ………………………… Thank you for your assistance. Course organizers6: ………………………………………………………………………………………… Course venue: ………………………………………………………………………………………………. Course dates: ………………………………………………………………………………………………. Course contact person’s name and address: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… 6 For example, ministry of health. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 21 3. Selecting trainers and participants The ministry of health or other agency may be planning a series of courses rather than a single course. Given the effort required to set up a course, the need to train trainers and for a series of courses to train a sufficient number of health workers, arrangements will often have to take into account longer term training plans. The concerned authorities in a specific location may decide to build a training team that can conduct courses on an ongoing basis. If so, long-term considerations may affect the choice of trainers and participants for each course. 3.1 Selecting trainers The success of a course depends on the presence of motivated, enthusiastic and knowledgeable trainers. When you select trainers, try to be sure that they will be interested and available to conduct other training courses in the future, and that they will be given support to do so. It is important that the experience gained by teaching a course is not wasted. The number of trainers will depend on the number of participants and the format of the course. 3.1.1 Trainer's profile Trainers should be knowledgeable about breastfeeding and health-care practices (including birth procedures) that are baby-friendly and in line with the Ten Steps to successful breastfeeding. The facilitators should be experienced in presentation skills and in the techniques of assisted learning. At least one of the course trainers should have a high level of breastfeeding knowledge and practice so they are able to answer questions and find further references. They should: • be convinced of the importance of breastfeeding, the Ten Steps to successful breastfeeding and the Baby-friendly Hospital Initiative; • be interested in becoming a trainer in the Baby-friendly Hospital Initiative training course for maternity staff; • be willing and available to conduct other courses in the future. Participation in this course does not qualify the person to become a trainer for this course. 3.1.2 Inviting trainers Invite trainers early and confirm their availability, so that you know how many participants you can invite. You will need one trainer for three to four participants. Include in the invitation the same information as in the course announcement for participants. Give the exact dates and make it clear that you expect them to attend the entire course. If trainers live near to where the course will be held, it might be useful to involve them early in the preparations for the course. It is hoped that trainers will teach on other courses and that some of them will become course directors. Building capacity of new trainers is as important as training participants. If this course is given as an intensive three days course, no one trainer should have primary responsibility for teaching more than three sessions in a day. Aim for a change of trainers frequently – at least for each session. Sessions may be divided with two or more trainers taking different sections to provide variety. Each trainer should have at least one hour of teaching responsibility daily. One trainer can do all the teaching if only one session is held on a single day, as may be likely in hospital in-service training. In order to learn effectively from the clinical practice and to safe guard the mothers and babies, there should be sufficient trainers to supervise the practice. Additional trainers may be available if there are already skilled staff on the wards or clinic who can assist. Each trainer should ideally have four and no more than six participants to supervize during clinical practice. If the course is conducted in short sessions over a period in one facility, clinical practice can be carried out by a small group of not more than six people with a trainer at a time convenient to their work. 3.2 Preparing trainers Preparing trainers will depend on the experience the trainers already have. During the preparation, new trainers need time to discuss the course content and structure, and to practise different teaching techniques involved in participatory Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 22 courses. All trainers need time to review the timetable, visit site facilities, check materials and equipment for their sessions and spend time learning how to assess participants for the follow-up assessment. Remember these points: • first arrange the times that are convenient for clinical practice sessions; • make sure that you include sessions of each kind, so that new trainers can practise different training methods, as needed; • allow time for the sessions that are most difficult to conduct. Be ready to change the timetable during the preparation, according to trainers’ progress, and to help them with particular difficulties. If the trainers have different levels of experience, you will need to arrange the preparation time to ensure their different preparation needs are met. 3.2.1 Outline of course training methods Distribute materials. Give each trainer a copy of the Trainer's guide, the Participant’s manual, the timetables for the course and the reference materials, if these have not been distributed previously. Explain the course structure and timetable Ask trainers to look at their copy of the timetable for the training course. Explain how the course is arranged with lectures, demonstrations, exercises, and clinical practice. Explain how training is conducted partly with the whole class together and partly in small groups of three or four participants with one trainer. Explain the objectives of the preparation. The objectives are: • to learn how to use the course materials, especially the Trainer's guide; • to become familiar with the information in the materials, and to discuss any points that are not clear; • to practise the practical and counselling skills that they will teach; • to practise the different teaching techniques, and to prepare to teach the different kinds of session; • to discuss the management of the course. Explain the principles of the course methods. The teaching methods used in the course are based on the principles listed below. • Instruction should be performance based. Instruction should teach participants the tasks that they will be expected to carry out on the job. This course is based on experience of what those involved. • Active participation increases learning. Participants learn how to do a task more quickly and efficiently if they actually do it, rather than just reading or hearing about it. Active participation keeps students more interested and alert. This course involves the participants actively in discussions, exercises and practical work. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 23 • Immediate feedback increases learning. Feedback is information given to a participant about how well they are doing. It is most helpful if it is given immediately. If a participant does an exercise correctly, praise them. They will be more likely to remember what they have learnt. If a participant does not do an exercise correctly, help them to clear up any misunderstandings before they become strong beliefs, or before they become more confused. In this course, trainers give immediate individual feedback on each exercise or practical task. • Motivation is essential for instruction to be effective. Most participants who come to a course are motivated and they want to learn. Trainers help to maintain this motivation if they: − provide immediate feedback − make sure that participants understand each exercise − encourage them in discussions − respect their original ideas and ways of responding − praise them for their efforts. 3.2.1.1 Discuss teaching various kinds of session There are several different kinds of session, and trainers should be able to conduct each kind. Presentations There are presentations in lecture form with slides. In the course for participants, each of these is conducted by one of the trainers, for the whole class together. Group work Some sessions are conducted in small groups of three to four participants with one trainer. These include practising counselling skills, role play, and practical and clinical practice sessions. 3.2.2 Methods used and training skills required The three methods below are used to demonstrate and practise teaching procedures. • The course director acts as a trainer. You demonstrate appropriate behaviours when giving a presentation, leading discussions, facilitating exercises or conducting a practical or clinical practice session. • A trainer practises giving a presentation, leading a discussion, facilitating an exercise or conducting a practical or clinical practice, while other trainers play the role of participants. Thus, the trainer both practises and demonstrates the role for other trainers. • One trainer acts as a “participant” doing a written exercise and another acts as a “trainer” providing individual feedback on their answer, while others observe them. Again, the “trainer” is both practising this teaching procedure and demonstrating for other trainers. Practise different kinds of sessions Arrange for each new trainer to practise as many of the different kinds of teaching techniques as possible, to: • give a presentation with slides • demonstrate counselling skills in a role-play • conduct group work with four participants • lead or assist in a practical or clinical practice session. Give feedback to trainers on their performance after each session they practise. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 24 Summarize the main training skills required. Giving lectures and using visual aids Ask the trainers to turn to the front of the Trainer’s guide and find the CHECKLIST OF TRAINING SKILLS. Read through and discuss the points mentioned in the list. Ask the trainers to practise these skills when they conduct their practice sessions. When you give feedback after their practice sessions, refer to this list. Giving individual feedback An important task of trainers is to provide individual feedback, for both the written exercises and the practical and clinical practice sessions. Giving individual feedback is not an easy technique to learn. It is very useful for new trainers to see it being modelled, and then for them to participate in the process so that they understand what is involved. When giving individual feedback, a trainer identifies points that the participant has and has not understood about an exercise and makes sure that the participant understands the main points. For written exercises, the trainer follows the possible answers in the Trainer's guide but accepts other answers that are also appropriate. If the participant’s answer is appropriate, the trainer gives praise. If the participant’s answer is not appropriate, the trainer discusses the question and helps the participant to think of a better answer. The trainer should not tell the participant the suggested answer too quickly. The opportunity should be used to clarify some of the teaching that the exercise is about and to help the participant think of appropriate responses. To practise the technique, one new trainer plays the part of a participant doing an exercise, while the other trainer gives individual feedback on their answer. They sit in front of the class, positioned as a trainer and participant would be, for others to observe and learn from their performance. The questions and comments of the “participant” trainer will probably not be characteristic of actual participants in a course, who may be shy and less well informed. Ask someone to act as a participant with such characteristics as: • fear of showing the trainer their work • confusion over the relationship of a previous exercise to the exercise being discussed • unwillingness to discuss an exercise at all • the tendency to say that they understand when they clearly do not. This will give new trainers a more realistic, if exaggerated, idea of the difficulties they may face. Remind trainers to speak quietly when they give feedback during the course. They should try to avoid disturbing people who are still working, try not to let other participants overhear the answers before they have thought about an exercise themselves, and try to give the participant who is getting the feedback some privacy. Trainers should sit down next to the participant with whom they are working, rather than standing over them, which can be intimidating. Preparing and giving a demonstration • Study the instructions and collect the equipment. • Prepare your assistant well beforehand. Conducting small-group sessions (practising counselling skills) Throughout the course, participants practise role-playing using their counselling skills. One participant plays the “mother”, another plays the “health worker”, and the other participant is the observer. The trainer guides participants and makes sure that they learn what is intended. The trainer helps the health worker to improve his or her skills. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 25 Helping participants In addition, trainers should ensure that participants have the forms and other items, as required, and be available to participants to answer questions between sessions. 3.2.3 Review the Trainer's guide and the other materials Ask the trainers to look at the Trainer's guide and at the Participant's manual and to compare the two. Make the following points. • The Participant's manual contains essential information for sessions that a participant needs to be able to remember or refer to. It contains the exercises and worksheets but no answers. • The Trainer's guide contains the same information, plus some further information to help to answer questions, and also detailed guidance on how to conduct each session, with possible answers to the exercises. Review the structure of a session in the Trainer's guide. Look at the beginning of a session, and point out the boxes for OBJECTIVES, SESSION OUTLINE and PREPARATION. Explain to the trainers that they should look at these sections before they conduct a session, so that they can make all necessary arrangements. Read the introduction to the Trainer's guide Ask the trainers to read through the Introduction of their Trainer’s guide carefully, as this contains important information about the course. Remind trainers when they prepare for their sessions, to read through the relevant sections of the Introduction to the Trainer’s guide, to remind them about the teaching methods they will use. • Ask the trainers to look at page 39 in the Trainer's guide, and to look at the box WHAT THE SYMBOLS USED IN THIS GUIDE INDICATE. Explain that these symbols are used throughout the guide, and they will soon become familiar. • Find an example of each symbol in the Trainer's guide. • Ask the trainers to look at that example, to see how the symbol is used. • Explain that if trainers follow the instructions in the Trainer's guide carefully, they will be able to conduct efficient and interesting sessions. • Explain that the Trainer's guide is their most essential tool for teaching the course. Suggest that they write their names clearly on their copy and keep it with them at all times. They can write notes in the guide that may be useful for training in future. Review other material Show trainers all the other materials, including worksheets and role plays. Explain briefly what each is for. 3.2.4 Practising the sessions Assign practice sessions to trainers On the first day of the preparation, assign sessions to trainers for them to practise teaching. Write their names on a copy of the timetable. Try to ensure that each new trainer practises giving a lecture, a demonstration, and facilitation group work during the preparatory days. If necessary, divide sessions between two or three new trainers, to make sure they have the necessary practise. For the first few practice sessions, select trainers who are more experienced or those whom you expect to be the best model for the less experienced trainers. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 26 Conduct the preparation New trainers should conduct their sessions as described in the Trainer’s guide, with other trainers as “participants”. For all the sessions, it is the course director’s responsibility to make sure that the necessary materials are available, and to give help as required. However, the trainers must request them, and make sure that they have everything ready. Discuss the teaching practice: ask questions such as “What did the trainer do well?”, “What difficulties did you observe?”, “What could the trainer do differently in the future?” After each practice session, trainers should discuss and comment on the teaching, referring to the CHECKLIST OF TRAINING SKILLS. Points to consider include the following. • Did the trainer’s movements and speech help the presentation? • Did they involve the class in discussion and answer questions clearly? • Did they explain points clearly, using the visual aids as needed? • Did the trainer use the Trainer's guide and other materials accurately? • Did they include all the main points? • Did they keep to time? Ask the class first to point out and praise what the trainer did well, and then to suggest what they could do differently. It is very important for the course director to praise a new trainer who has followed the material and conducted a session well. But it is also important to help new trainers to improve their teaching skills. It is helpful to discuss ways to improve with the whole group, because then everybody learns. However, if you feel that some points may embarrass a new trainer, you may need to discuss them privately. As course director, you should also encourage discussion of your own technique after you have demonstrated a session. Show that you welcome suggestions about how to conduct the session better. Troubleshooting: Trainers' difficulties Discuss difficulties that the trainers had doing the exercises and discuss how they can help participants if they have similar difficulties. Sometimes a trainer shows that they find it particularly difficult to teach a session. This might be for example because of lack of confidence, or because they were unable to prepare well enough beforehand. If this happens, discuss their performance with them privately and not with the whole group. It might also be useful to help them to prepare for their next session, so that they can develop more confidence. 3.2.5 Review the timetable Ask trainers to look at the timetable for the participants’ course and read it through. Go through all the sessions, and check who is responsible for conducting each one. Remind trainers that they will all need to actively assist in sessions that include group activities. Make sure that trainers all agree with what you have asked them to do. Give them the information in writing. 3.2.6 Visit sites for practical sessions Visit the teaching facility and ensure that the trainers know where the classrooms and the practical cooking areas are, and the arrangements for meals. Check the equipment Check that the projector, electrical extension cords if needed, flipchart and all other equipment is in place, or that the trainers know where to obtain it. Make the following clear: Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 27 • who is responsible for providing materials, stationery, and equipment; appoint someone whom trainers can contact if they need something; • that you will be holding daily trainers’ meetings of about half to one hour, which are very important for the success of the course; discuss an acceptable time (usually at the end of the day); • time may be needed in the evenings after the session, to prepare and practise the next day’s sessions; • who is responsible for assigning participant groups to trainers; explain that the list will be prepared on the first morning of the course, after participants have registered. 3.2.7 Thank the trainers for their efforts Thank the trainers for their work during the preparation. Encourage them to continue working hard during the course itself and promise to help them in any way that they need. 3.2.8 Trainers’ meetings • Trainers’ meetings are usually conducted for about 30–60 minutes at the end of each day. Trainers will be tired, so keep the meetings brief. They should be led by the course director(s). • Begin the meeting by encouraging the trainers – praising what they did well during the day. Trainers may become discouraged if they feel the session(s) they led did not go well. • Continue by asking a trainer from each group to describe progress made by their group, to identify any difficulties impeding progress, and to identify any skill, exercise or any section of the sessions that participants found especially difficult to do or understand. • Identify solutions to any problems related to any particular group's progress or related to difficult skills or sections of the sessions. • Discuss teaching techniques that the trainers have found to be successful. • Provide feedback to the trainers on their performance. Use the notes that you have taken while observing the groups during the day. • Mention a few specific actions that were well done (for example, conducting a lecture session accurately and in an interesting way; keeping to time; providing participants with individual feedback; facilitating a practical session well; demonstrating practical skills carefully and accurately to the group). • Mention a few actions that might be done better (for example, keeping to time; following the lecture sessions accurately without omitting any points; answering questions clearly; explaining more clearly which tasks should be practised during the practical or clinical practice session). Remind trainers of certain actions that you consider important. Some examples are listed below. • Discuss difficulties with a co-trainer. If co-trainers cannot solve problems together, go to the course director. The course director may be able to deal with these situations (for example, by discussing matters privately with concerned individuals). • Speak softly while giving feedback, to avoid disturbing others. Put chairs out in the hall so that a participant and a trainer can talk without disturbing the rest of the group. • Always be open to questions. Try to answer immediately, but if a question takes too long to answer, diverts the attention of the group from the main topic, or is not relevant at that moment, suggest that the discussion be continued later (for example, during free time). If a question will be answered later in the course, explain this. If unsure of the answer to a question, offer to ask someone else and then come back later with an explanation. • Interact informally with participants outside of scheduled class meetings. • For participants who cannot read the sessions and/or do the exercises as quickly as others, the trainers should: − avoid doing exercises for them − reinforce small successes − be patient (or ask another facilitator to help). Before closing the meeting raise the following. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 28 • Review important points to emphasize in the clinical practice session or in the sessions the next day. • Remind the trainers to consult the Trainer’s guide and gather together any supplies needed for the next day. • Make any necessary administrative announcements (for example, the location of equipment for the demonstrations, room changes, transportation arrangements, etc.). 3.3 Selecting participants Try to ensure that appropriate and motivated participants come to the course. This will make the training successful and may stimulate the interest of others, so that they will also want to acquire the skills and do the work. Participants should be free of other work during the course, so that they can fully participate. The number of participants who can be invited for a course depends on: • your budget • classroom and residential accommodation • the number of trainers available (you need one trainer for each four participants) • the number of who can be seen on an average day in the facility where you will conduct the clinical practice sessions (per session per group of four participants). It is recommended that you do not invite more than 24 participants to a course. If possible, try to include one or more of the staff of the health facility in which the clinical practice sessions will be conducted. You may plan to train a number of people from a certain area, or to train all appropriate health workers in a given area or institution with a series of trainings. You may like to ask directors of health facilities in an area to select one to three participants to attend the course. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 29 3.4 Sample: Course announcement TABLE 5. EXAMPLE OF COURSE ANNOUNCEMENT Date: …………………………………………………………………………………………………… Venue: …………………………………………………………………………………………………. Course organizers7: ……………………………………………………………………………….. Objectives of the course: After completing this course, participants should be able to assess breastfeeding for mothers and their newborn babies, provide assistance to help a mother and newborn with breastfeeding, and identify and manage common breastfeeding difficulties. Participants will also be able to talk with mothers in the antenatal and immediate postpartum periods and support them in their infant feeding decisions. Overall, participants will be able to implement the global recommendations of exclusively breastfeeding for six months with continued breastfeeding for up to two years and beyond. Participants will be competent in implementing the Ten Steps to Successful Breastfeeding in the facilities where they work. Who should attend: The course is for health workers such as nurses and doctors. They should be fluent in (state required language). Outline of course: (Section to be completed according to the content selected.) Accommodation: Accommodation and meals will be available from (evening before course to morning after depending on travel arrangements). Participants should arrive by 08:00 hours on (first day of course) and are free to leave after 17:00 hours on (last day of course). Travel costs will be reimbursed. Registering for the course: Send the names and contact details of candidates who wish to apply, to (name and address) before (date). When participants have been selected, further information will be sent to them and to their health facility. 7 For example, ministry of health. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 30 4. Planning checklists 4.1 Checklist: Overall planning In the following pages, you will find the checklists referred to in the preceding pages. You can tick off each item as it is completed. If the course director has to travel far, a local organizer may arrange these actions. 4.1.1 Initial planning 1. Course schedule Decide on the schedule for the course. For example, a three-day course or one-day meeting each week for three weeks. Allocate eight teaching hours per day with additional mealtimes. 2. Training venue Choose a large classroom, two to three smaller classrooms and a facility to conduct the clinical practice sessions. Ideally, these should be at the same site. Make sure that the following are available: • easy access from the classroom to the area for clinical practice sessions; • a large room that can seat all participants and trainers for sessions, including space for guests invited to the opening and closing ceremonies; • space for participants and trainers to sit at a table with their course material; • adequate lighting and ventilation; • wall space to post large sheets of paper in each of the rooms; • one table for each group of six to eight participants; • table space to hold the projector, display materials and for the trainer’s use; • a blackboard, white board or flipchart (and chalk or markers) in the front of the room for writing; • a notice board or wall to display materials; • tape for attaching notices to the wall; • easy access to a data projector for the slides; • extension cords; • screen or suitable wall or equipment to project course materials; • less noise disturbance; • arrangements for refreshments; • space for at least one member of clerical or logistic support staff during training; • a place where supplies and equipment can be safely stored and locked up daily. NOTE: When you have chosen a site, confirm the booking in writing. Then, reconfirm some time before the course and again shortly before the course. 3. Lodging Choose optional lodging for participants. Ideally, this should be a residential course. If lodging is at a different site from the course, make sure that the following are available: • reliable transportation to and from the course site; • meal service that is convenient for the course timetable. NOTE: When you have identified lodgings, confirm the booking in writing and reconfirm some time before the course and again shortly before the course. 4. Site visit Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 31 Visit the health facility or other facilities you will use for the clinical practice sessions. • Confirm timings when it is possible to see mothers and their newborn babies. • If you plan to visit more than one facility in each clinical practice session, it is important to make sure mothers/babies are available at the same time. • When you have chosen a site, confirm it in writing and reconfirm shortly before the course. 5. Set the course dates. 6. Arrange for an authority (for example, the Ministry of Health) to send a letter to the district/regional office or to health facilities asking them to identify participants. This letter should: • explain the course will be conducted; • explain the course objectives; • give the site and dates of the course; • state the total number of participants for the course (12–24); • suggest the number of places to offer to participants from each facility (this depends on how many facilities are involved); • state clearly that nominated participants should be people who are responsible for caring for mothers and their newborns in facilities providing maternity and newborn services; • explain the duration of the course; • explain that individuals should arrive on time and attend the entire course; • give the selection date for course participants include the name of the contact person for the course; • say that a letter of invitation will be sent to participants once they are selected. 7. Select and invite trainers. It is necessary that: • there is at least one trainer per four participants • trainers should be experienced (see section 3.1) • trainers are able and willing to attend the entire course, including the preparatory period. 8. Identify suitable participants, and send them letters of invitation, stating (see section 3.3): • the objectives and description of the course • arrival and departure times for participants • that it is essential to arrive on time and to attend the entire course • administrative arrangements, such as accommodation, meals and payment of other costs. 9. Obtain enough copies of the course materials (see section 4.2). 10. Arrange to obtain: • necessary supplies and equipment (see section 4.3) • the items needed for demonstrations (see section 4.4) • the necessary background information for the area (see section 4.5). 11. Arrange to send materials, equipment and supplies to the training venue. 12. Arrange to send travel authorizations to trainers and participants. 13. Invite officials for the opening and closing ceremonies (see section 1.11). Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 32 4.1.2 Arrangements before the course begins A designated person should arrive early at the course site to ensure that all the arrangements have been made. This can be either the course director or one of the trainers. Plan to arrive at least a day or two before the preparatory period for trainers and continue with the organization during the preparatory days. During the course, the course director needs to work with local staff to ensure that the arrangements move forward and the trainers’ and participants’ work is not interrupted. 14. Confirm arrangements for: • lodging for all trainers and participants; • classrooms; • daily transportation of participants from lodgings to the classroom and to and from clinical practice session sites; • the clinical practice sessions and that clinic staff are briefed on the visits, ensuring that newborns/mothers will be available when needed and determining a suitable way of thanking the mothers for their time; • meals and refreshments; • opening and closing ceremonies with relevant authorities; check that invited guests are able to come; • a Course-completion certificate; • timing for group photo (optional); • arrangements for typing and copying of materials during the course (for example, timetables, lists of addresses of participants and trainers). 15. Arrange to welcome trainers and participants at the hotel, airport or railway/bus station 16. Prepare timetables for preparation of trainers and for course participants. 17. Adapt the EVALUATION QUESTIONNAIRE FOR PARTICIPANTS Make enough copies for each trainer and participant (see section 6). 4.1.3 Actions during the preparation of trainers 18. Provide a timetable for the training-of-trainers on the first day. 19. Assign pairs of trainers to work together during the course. 20. Assign trainers to conduct sessions. 21. Organize course materials, supplies and equipment, and place them in the appropriate rooms at the course site. 4.1.4 Actions during the course 22. After registration, assign groups (three to four participants to one trainer). Post the list of participants assigned to the different pairs of trainers. 23. Provide course directory to all participants and trainers, including the names and addresses of all participants, trainers and the course director. 24. Arrange for a group photograph. 25. Prepare a COURSE-COMPLETION CERTIFICATE for each participant. 26. Make arrangements to reconfirm or change air, train or bus reservations for trainers and participants, if necessary. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 33 Additional check points: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 34 4.2 Checklist: Course materials Materials needed for the course with 24 participants and six trainers (with two extras, if required). Note: Some materials are related to specific modules and should only be used if the module is included in the training: TABLE 6. CHECKLIST FOR COURSE MATERIALS Item No. of copies Director and trainers Participants Director’s guide 8 ✔ – Trainer's guide 8 ✔ – Sets of slides 1 per group – Participant's manual 32 ✔ ✔ TABLE 7. COURSE MATERIALS TO BE PHOTOCOPIED Item No. of copies Director and trainers Participants Course timetable for trainers (if included) 8 ✔ – Course timetable for participants 32 ✔ ✔ Course registration form 30 ✔ ✔ Summary participant list 1 ✔ – Evaluation questionnaire for participants 30 – ✔ Evaluation form for participants and trainers 30 ✔ ✔ Evaluation form for trainers 8 ✔ – LISTENING AND LEARNING SKILLS CHECKLIST 32 ✔ ✔ COUNSELLING SKILLS CHECKLIST (including listening and learning skills and skills for building confidence and giving support) 32 ✔ ✔ CLINICAL PRACTICE DISCUSSION CHECKLIST (with communication skills on back) 8 ✔ – COMPETENCY PROGRESS FORM 30 ✔ ✔ JOB AID: BREASTFEEDING SESSION OBSERVATION 64 ✔ ✔ JOB AID: ANTENATAL CHECKLIST (OPTIONAL) 32 ✔ ✔ JOB AID: BIRTH PRACTICES FORM (OPTIONAL) 32 ✔ ✔ ASSESSING AND CHANGING PRACTICES FORM (IF USED) 30 ✔ ✔ LOG OF SKILLS PRACTISED 26 – ✔ DIFFICULTIES EXPERIENCED 26 – ✔ Copies of demonstrations 2 of each – For participants helping with demonstrations Answer sheets 24 – 1 per participant Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 35 4.3 Checklist: Equipment and stationery TABLE 8. CHECKLIST FOR EQUIPMENT AND STATIONERY Items needed Number needed for the course Laptop 1 PowerPoint projector 1 Equipment for typing/word processing Access needed Photocopying equipment Access needed Photocopying paper Two reams (200 sheets) for timetables and other incidentals. Flipchart stands or blackboards 3 Markers for flipchart 3 each of red, black and green Chalk 2 boxes Chalk erasers 2 Name tags and holders 32 Pads or notebooks of ruled paper 32 No. 2 pencils 32 Erasers 32 Ballpoint pens – blue or black 32 Highlighters 32 Hand-held staplers 2 Staples 1 box Scissors 2 pairs Pencil sharpeners 5 Paper clips, large Approx. 100 Masking tape to stick flipchart sheets onto walls or other surfaces 2 rolls Simple files for trainers to store papers 10 4.4 Checklist: Items needed for demonstration 4.4.1 General • Four chairs for demonstrations • Four life-size baby dolls (these can be made yourself, if necessary) • One model breast (this can be made yourself, if necessary) 4.4.2 Individual sessions Session 1: BFHI: A key component of quality maternal and newborn care • Poster: TEN STEPS TO SUCCESSFUL BREASTFEEDING (provided at the end of Session 1 Trainer’s Guide) Session 9: Clinical practice: Positioning a baby at the breast • A doll (preferably one per participant for role-playing, if available) • Pillows and a blanket • Somewhere for the “mother” to lie down, e.g. a bed or a table • A model breast Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 36 Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 37 Session 15: Alternative feeding methods • Some examples of containers to collect expressed breast milk which would be available to mothers (for example cups, jam jars) • Optional: Some examples of locally available breast pumps (if any are used in your area) • A small cup (available locally) that can be used for cup-feeding a newborn. The cup should hold 60 mL of fluid. • A cloth or bib • A doll • A model breast Session 11: Breast and nipple conditions • A 20 mL disposable syringe • A model breast Session 22: Facility practices: Implementing the Ten Steps • Breastfeeding policy for a local “baby-friendly hospital”, if available 4.5 Checklist: Background information needed • What are the follow-up plans for course participants? • What are local breastfeeding rates? • What is the infant feeding policy for local hospitals and clinics? • What is the prevalence of HIV? Are there regional differences? • What is the national health authority infant-feeding recommendation for mothers living with HIV? • In what ways are breast-milk substitutes promoted, advertised, or marketed locally? • What is the national legislation, regulations and monitoring systems surrounding The International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly (WHA) resolutions (the Code)? 4.6 Sample timetable There is some flexibility in the timetable, but the course director should make such decisions. 1. What is the best time to conduct clinical sessions? Determine the best times to conduct clinical sessions. Then, build the classroom sessions around the visits to the wards/facilities. Ensure the classroom knowledge on a topic comes before the clinical session for that topic. For example, you will need to cover topics about practices supporting breastfeeding (early contact and rooming-in). This will be followed by the clinical session with pregnant women. 2. How many trainers are present? What is their skill level? The number of trainers and their particular skills also need to be taken into account. Planning the timetable may mean shifting trainers for specific topics. Please consider when equipment is available, timing of meal breaks and whether travel time is needed to reach clinical sites. A sample timetable is provided below. 3. Will there be time for additional sessions? Time for the course material is indicated. This does not include additional information sections or optional activities. Arrange clinical sessions first and then plan the classroom sessions around these practices. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 38 4.7 Sample: Course timetable (held over 3 days) TABLE 7. EXAMPLE OF COURSE TIMETABLE Day 1 Day 2 Day 3 08:30–08:45 Welcome, distribution of materials and discussion of competencies 08:30–10:30 Session 10: Clinical practice session 1: 1)Listening and learning 2) Assessing a breastfeeding session 08:30–10:30 Session 16: Clinical practice session 2: 1) Building confidence and giving support 2) Assisting breastfeeding session 08:45–09:15 Session 1: BFHI: A key component of quality maternal and newborn care 09:15–10:00 Session 2: Benefits of breastfeeding 10:30–11:00 10:30–11:00 Tea and coffee 10:30–11:00 Tea and coffee 10:00–10:30 Tea and coffee 11:00–12:15 Session 11: Breast and nipple conditions 11:00–11:30 Session 17: Maternal health 10:30–11:15 Session 3: Counselling skills: Listening and learning 11:30–12:15 Session 18: Antenatal preparation for breastfeeding 11:15–12:00 Session 4: Counselling skills: Building confidence and giving support 12:15–13:15 Lunch 12:15–13:15 Lunch 12:00–13:00 Lunch 13:15–14:15 Session 12: Milk supply issues 13:15–14:45 Session 19: Clinical Practice Session 3: Counseling a pregnant woman 13:00–13:45 Session 5: How breastfeeding works 13:45–14:30 Session 6: Impact of birth practices 14:15–15:00 Session 13: Barriers to breastfeeding 14:45–15:15 Session 20: Discharge care 14:30–15:15 Session 7: Postnatal practices to support breastfeeding 15:00–15:15 Break 15:15–15:30 Break 15:15–15:30 Break 15:15–16:00 Session 14: Medical indications for supplementary feeding 15:30–16:15 Session 21: The International code of marketing of breast-milk substitutes and subsequent relevant World Health Assembly resolutions 15:30–16:15 Session 8: Assessing a breastfeeding 16:15–17:15 Session 9: Clinical practice: Positioning a baby at the breast 16:00–17:00 Session 15: Alternative feeding methods 16:15–16:45 Session 22: Facility practices: Implementing the Ten Steps 16:45–17:00 Closing remarks Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 39 5. Course tools to photocopy 5.1 Registration and evaluation Course registration form Please print clearly Your name: _________________________________________________ Email address: ____________________________________________________ Mailing address: ____________________________________________________ ____________________________________________________ ___________________________________________________ Health facility name and address where you work: ____________________________________________________ ____________________________________________________ What is your current work position or job title? What are your current duties related to working in a facility providing maternity and newborn services? What professional training in health have you previously received? What year did you complete your basic training in health? Indicate any course(s) related to breastfeeding, infant and young child feeding, newborn health, or postnatal/postpartum care in which you have participated. Note whether you are a trainer/facilitator. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 40 Summary of participants list Dates of course:__________________ Name of course: __________________ Location of course:____________________ Name of participant Email address Mailing address Name of participant’s health facility Current position or job title Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 41 Participant’s evaluation questionnaire Baby-friendly Hospital Initiative: A training course for maternity staff To improve the training for others in the future, please complete this questionnaire 1. Briefly describe your responsibilities in relation to mothers and babies. In what type of setting do you work (e.g. community, private practice, health centre, hospital)? 2. Did you find any aspect of the training difficult (try to think in terms of “knowledge” and “skills”)? Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 42 3. For each activity listed below, tick one box to show whether you thought that the time spent on the activity was too short, adequate or too long. Type of activity Time spent Too short Adequate Too long Theory–lecture sessions Demonstration of practical skills Demonstration of counselling skills Clinical practice sessions 4. What additional support, do you think you may need after this training to enable you to implement or improve the Ten Steps to Successful Breastfeeding for mothers/parents/caregivers and newborns in your own work setting? 5. How could the content and/or management of this training course be improved for future participants? Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 43 6. Please evaluate the usefulness of each session delivered during this course. Title of session Very useful Useful Somewhat useful Not useful Comments Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 44 Baby-friendly Hospital Initiative: A training course for maternity staff Evaluation form for participants and trainers Please rate the level of difficulty in applying the following knowledge, skills and in implementing the Ten Steps to Successful Breastfeeding. For each question below, put a check (√) in the box that best describes the level of difficulty. 1 = Not at all difficult, 2 = Not difficult, 3 = Neutral (not sure), 4 = Difficult, 5 = Very difficult How difficult is it for you to… 1 2 3 4 5 1. Use the listening and learning skills to counsel a mother/parent/caregiver 2. Use the skills for building confidence and giving support to counsel a mother/caregiver 3. Assess a feeding using the JOB AID: BREASTFEEDING SESSION OBSERVATION 4. Help a mother to position her baby for breastfeeding using the FOUR KEY POINTS OF POSITIONING 5. Explain the FOUR KEY POINTS OF ATTACHMENT for breastfeeding 6. Help a mother to attach her baby to the breast once they are well positioned 7. Describe the importance of exclusive breastfeeding for six months and continued breastfeeding for up to two years and beyond 8. Explain to a mother about responsive feeding and its implications for the frequency and duration of breastfeeding 9. Explain to a mother the steps of expressing breast milk by hand 10. Practise with a mother how to cup feed her baby safely 11. Counsel a pregnant woman about breastfeeding and infant feeding 12. Explain the importance of skin-to-skin contact immediately after delivery and the initiation of breastfeeding within one hour 13. Describe how health-care practices affect initiation of breastfeeding 14. List the signs and symptoms that indicate a newborn may not be getting enough milk 15. Explain the common reasons why newborns may have a low intake of breast milk 16. Explain how to prevent and manage milk insufficiency in newborns 17. Recognize breast refusal and help a mother to breastfeed 18. List the different reasons why a newborn may cry often 19. Help a mother who has flat or inverted nipples 20. Help a mother with engorged breasts 21. Help a mother with sore or cracked nipples 22. Help a mother with mastitis 23. Describe alternative methods of feeding 24. Counsel a mother about her own health 25. Implement the International Code of Marketing of Breast-Milk Substitutes in a health facility Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 45 Baby-friendly Hospital Initiative: A training course for maternity staff Evaluation form for trainers Please rate the level of difficulty in applying the following facilitation skills for training in the Ten Steps to Successful Breastfeeding. For each question below, put a check (√) in the box that best describes the level of difficulty for you. 1 = Not at all difficult, 2 = Not difficult, 3 = Neutral (not sure), 4 = Difficult, 5 = Very difficult How difficult is it for you to… 1 2 3 4 5 1. Take the lead during a classroom or clinical session 2. Face the audience (not the board or screen) while speaking 3. Make eye contact with people in the audience 4. Use gestures and facial expressions while leading a classroom session 5. Avoid blocking the view of the audience 6. Speak slowly and clearly, and loud enough for everyone to hear 7. Speak naturally and in a lively manner – varied level and tone of voice 8. Use a microphone 9. Interact with all participants 10. Use participants’ names 11. Ask the questions suggested in the text to different participants 12. Allow time for participants to answer 13. Respond positively to all answers to your questions (correct errors gently) 14. Involve all participants (include quiet ones and control talkative ones) 15. Postpone or cut short discussions that are off the point or distracting 16. Give satisfactory answers to questions from participants 17. When you do not know the answer, explain that you don't know the answer but will find it 18. Prepare training aids and equipment and arrange them in the room before the session 19. Remove training aids and equipment from the room after use 20. Arrange the room so that everyone can see clearly and participate in discussions 21. Write clearly on the flipchart or writing board 22. Lead sessions accurately and completely – including all important points 23. Give local examples when needed 24. Keep to time – not too fast and not too slow 25. Avoid losing time between sessions 26. Prepare participants for practical session 27. Select appropriate mothers and newborns during clinical practice sessions 28. Demonstrate appropriate counselling skills to participants 29. Lead a discussion after a practice session in the clinic or classroom 30. Give positive feedback to participants about their performance (i.e. praise and compliments) 31. Give feedback to help participants overcome difficulties (i.e. constructive) 32. Facilitate Baby-friendly Hospital initiative courses in your own context or country Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 46 5.2 Job aids and checklists For general use, or specifically for clinical practice sessions SKILLS CHECKLIST: LISTENING AND LEARNING Name of counsellor: _________________________________________________________ Name of observer: __________________________________________ Date of visit: ______________________________________________________ (√ for Yes and × for No) Counsellor: Listening and learning skills ❑ Keep the head level with mother/parent/caregiver ❑ Pay attention (eye contact) ❑ Remove barriers (tables and notes) ❑ Take time? Allow the mother/parent/caregiver time to talk ❑ Use appropriate touch ❑ Ask open questions ❑ Use responses and gestures showing interest ❑ Reflect back what the mother/parent/caregiver said ❑ Empathize – showing he or she understood how the mother/parent/caregiver feels ❑ Avoid using judging words Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 47 COUNSELLING SKILLS Name of counsellor: _________________________________________________________ Name of observer: __________________________________________ Date of visit: ______________________________________________________ Listening and learning skills • Use helpful non-verbal communication • Ask open questions • Use responses and gestures showing interest • Reflect back what the mother/parent/caregiver says • Empathize – show you understand how the mother/parent/caregiver feels • Avoid using judging words Building confidence and giving support skills • Accept what a mother/parent/caregiver thinks and feels • Recognize and praise what a mother/parent/caregiver and baby are doing well • Give practical help • Give specific, relevant information • Use simple language • Make one or two suggestions, not commands Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 48 CHECKLIST: CLINICAL PRACTICE DISCUSSION Practical skills are best developed by: 1) Introducing and demonstrating the skills 2) Observing participants as they practise the skills 3) Giving feedback to participants on how well they performed. Feedback should include: 1) Praising participants for things done well 2) Giving gentle suggestions for how to overcome difficulties. Use the checklist below to help guide your feedback discussions Questions to ask each counsellor To the counsellor: • What did you do well? • What difficulties did you have? • What would you do differently in the future? To the observer: • What did the counsellor do well? • What difficulties did you observe? Listening and learning skills • Which listening and learning skills did you use? • Was the mother willing to talk? • Did the mother ask any questions? How did you respond? • Did you empathize with the mother? Give an example. Skills for building confidence and giving support • Which confidence and support skills were used? (Check especially skills to praise and for two relevant suggestions) • Which skills were most difficult to use? • What was the mother's response to your suggestions? General questions • What special difficulties or situations helped you to learn? • What was the most interesting thing you learned from this practical session? Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 49 COMPETENCY PROGRESS FORM After each clinical practice, put a ✓ in the boxes for each skill you have practised. For each mother and baby that you see, you can put a ✓ in one or more boxes. Discuss your progress with your trainer and try to practise as many competencies as possible. Core competencies 1. Using listening and learning skills whenever engaging in a conversation with a mother (using list of 6 skills) 2. Using skills for building confidence and giving support whenever engaging in a conversation using listening and learning skills to counsel a mother (using list of 6 skills) 3. Engaging in antenatal conversation about breastfeeding (early contact, exclusive breastfeeding for six months, and continued breastfeeding to two years, and responsive feeding) 4. Implementing immediate and uninterrupted skin-to-skin 5. Facilitating breastfeeding within the first hour, according to cues 6. Discussing with a mother how breastfeeding works 7. Assisting a mother getting her baby to latch (using JOB AID: BREASTFEEDING SESSION OBSERVATION) 8. Helping a mother respond to feeding cues 9. Helping a mother manage milk expression 10. Helping a mother to breastfeed a low-birth-weight or sick baby 11. Helping a mother whose baby needs fluids other than breast milk 12. Helping a mother who is not feeding her baby directly at the breast 13. Helping a mother prevent or resolve difficulties with breastfeeding 14. Ensuring seamless transition after discharge 15. Implementing the International code of marketing of breast-milk substitutes in a health facility 16. Explaining a facility’s infant feeding policies and monitoring systems Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 50 Job aids and reference tools JOB AID: BIRTH PRACTICES CHECKLIST Date and time of birth: ____________________ Companion for delivery: yes/no Time started _____ Time ended ____ Type of birth: ___ Vaginal : Natural ___ Vacuum ___ Forceps ___ Position for vaginal delivery: ___ C-section with epidural/spinal ___ C-section with general anaesthetic Skin-to-skin contact: Position of mother: Time started: ______ Time ended: _______ Duration of contact: ________ Reason for ending skin-to-skin contact: __________________________________ __________________________________________________________________ Time of baby’s first breastfeed: ____________________ Initiated by baby: _____________ Helped by: ________________________ Date and time help offered with second breastfeed: _________________________ Notes: ________________________________________________________________ Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 51 JOB AID: ANTENATAL CHECKLIST – INFANT FEEDING All of the following should be discussed with all pregnant women by 32 weeks of pregnancy. The health worker discussing the information should sign and date the form. Name:_______________________________________________________________________ Expected date of birth:________________________________________________________ Topic Discussed or note if mother declined discussion Signed Date Listening to mother’s ideas, previous experience and anxieties regarding infant feeding Importance of exclusive breastfeeding to the baby No other foods or drink needed for the first 6 months – only mother’s milk Importance of continuing breastfeeding after 6 months while giving other foods (protects against many illnesses; helps baby to grow and develop well; changes with baby’s needs, babies who are not breastfed are at higher risk of illness). Importance of breastfeeding to the mother (protects against breast cancer and hip fractures in later life, helps mother form close relationship with the baby, artificial feeding costs money) Importance of skin-to-skin contact immediately after birth (keeps baby warm and calm, promotes bonding, helps breastfeeding get started) Early initiation of breastfeeding (helps establish breastfeeding, baby receives colostrum) Importance of good positioning and attachment (good positioning and attachment helps the baby to get milk, and for mother to avoid sore nipples and sore breasts, practice with a doll, help is available from community resources) Getting feeding off to a good start - responsive feeding; - knowing when baby is getting enough milk; - importance of rooming-in/keeping baby nearby; - risks of using artificial teats, bottles and pacifiers. Risks of not breastfeeding - loss of protection from illness and chronic diseases; - contamination, errors of preparation; - risks of bottles and artificial teats difficulty in reversing the decision not to breastfeed. Other points discussed, and any follow-up or referral needed: Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 52 JOB AID: BREASTFEEDING SESSION OBSERVATION Mother’s name _______________________________ Date ____________________ Baby's name _________________________________ Baby's age ______________ Signs that breastfeeding is going well: Signs of possible difficulty: GENERAL Mother Mother  Mother looks healthy  Mother looks ill or depressed  Mother relaxed, comfortable, back supported  Mother looks tense and uncomfortable  Signs of bonding between mother and baby  No mother/baby eye contact Baby Baby  Baby looks healthy  Baby looks sleepy or ill  Baby calm and relaxed  Baby is restless or crying  Baby reaches or roots for breast if hungry  Baby does not reach or root BREASTS  Breasts look healthy  Breasts look red, swollen or sore  No pain or discomfort  Breast or nipple painful  Breast well supported with fingers  Breast held with fingers on areola away from nipple BABY’S POSITION  Baby’s head and body in line  Baby’s neck and head twisted to feed  Baby held close to mother’s body  Baby not held close  Baby’s whole body supported  Baby supported by head and neck only  Baby approaches breast, nose to nipple  Baby approaches breast, lower lip/chin mouth above nipple to nipple BABY’S ATTACHMENT  More areola seen above baby’s top lip  More areola seen below bottom lip  Baby’s mouth wide open  Baby’s mouth not open wide  Lower lip turned outwards  Lower lips pointing forward or turned in  Baby’s chin touches breast  Baby’s chin not touching breast SUCKLING  Slow, deep sucks with pauses  Rapid shallow sucks  Cheeks round when suckling  Cheeks pulled in when suckling  Baby releases breast when finished  Mother takes baby off the breast  Mother notices signs of oxytocin reflex  No signs of oxytocin reflex noticed Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 53 General assessment and follow-up ASSESSING AND CHANGING PRACTICES FORM PRACTICE YES/NO What is done well, and/or main improvement needed Critical management procedures The International Code of Marketing of Breast-milk Substitutes (the Code) Step 1a • Does your facility prohibit the display or promotion of products covered under the Code (breast-milk substitutes, feeding bottles and teats)? • Does your facility prohibit items with logos of companies that produce breast-milk substitutes, feeding bottles and teats? • Does your facility prohibit receiving free or subsidized supplies of infant formula, feeding bottles and teats? Infant feeding policy Step 1b • Does your facility have an infant feeding policy? • Is this a written policy? • Does it cover the eight key clinical practices of the TEN STEPS TO SUCCESSFUL BREASTFEEDING? • Does the policy cover the Code? • Is the policy routinely communicated to staff and parents? • Is the policy visible to pregnant women, mothers and their families? Step 1c Monitoring and data-management systems • Does your facility have a protocol for ongoing monitoring of the eight key clinical practice of the Ten Steps? Staff Competency Step 2 • Are staff provided with training on supporting mothers to breastfeed? • Is there an assessment of knowledge and skills for health workers on supporting breastfeeding? Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 54 Antenatal information Step 3 • Do you offer/provide antenatal counselling on breastfeeding? • Do you inform all pregnant women and their families about: - the importance of breastfeeding - the importance of exclusive breastfeeding for the first six months - the risks of giving formula or other breast-milk substitutes - continued breastfeeding after six months when complementary foods are given - the importance of immediate and sustained skin-to-skin contact - the importance of rooming-in - the basics of good positioning and attachment - recognition of feeding cues? Immediate postnatal care Step 4 • Are mothers of term infants placed in skin-to-skin contact with them immediately or within five minutes after birth? • Does this contact last for one hour or more unless there are documented medically justifiable reasons for delayed contact? • Are mothers of term infants put to the breast within one hour after birth? Supplementation Step 6 • Are babies only given breast milk (unless medically indicated?) - Is donor human milk prioritized if a supplement is needed? • Are mothers who want to formula feed helped to do so safely? Rooming-in Step 7 • Do mothers and infants remain together day and night? • Are mothers of low-birth-weight and sick babies encouraged to stay near their babies? Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 55 Responsive feeding Step 8 • Do you encourage mothers to practise responsive feeding with their infants - as often as the baby wants to feed - no restrictions on length of breastfeeds? Feeding bottles, teats and pacifiers Step 9 • Are mothers counselled on the use and risks of feeding bottles, teats and pacifiers? • Do you use feeding bottles for babies whose mothers intend to breastfeed? Care at discharge Step 10 • Do you discuss with mothers the support they have when they are at home? • Do you refer all mothers for follow-up care two to four days after delivery, to make sure that breastfeeding is going well, and to give early help with any difficulties? • Do you refer all mothers for follow-up in the second week after delivery, to make sure that breastfeeding is going well, and to give early help with any difficulties? • Are you able to refer mothers to lactation support resources in the community? • Are you able to give extra help and support to mothers and babies with special needs, so that they can continue to breastfeed, for example: - low-birth-weight babies or sick babies - babies with disabilities - if the mother is sick or has a disability - if the mother is living with HIV and has decided to breastfeed (if this is national policy)? • Do you encourage women to breastfeed exclusively for six months? • Do you encourage women to continue breastfeeding for up to two years and beyond with complementary feeding? Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 56 Changes that health workers could make themselves (Make 5–10 practical suggestions) 1. 2. 3. 4. 5. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 57 6. 7. 8. 9. 10. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 58 Changes that require management support (List 1–4 helpful management changes) 1. 2. 3. 4. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 59 LOG OF SKILLS PRACTISED Date Skill practised Comments Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 60 DIFFICULTIES EXPERIENCED Date Difficulty experienced Comments Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 61 5.3 Other items of key information COMMUNICATION SKILLS Listening and learning skills • Use helpful non-verbal communication • Ask open questions • Use responses and gestures showing interest • Reflect back what the mother/parent/caregiver says • Empathize – show you understand how the mother/parent/caregiver feels • Avoid using judging words Building confidence and giving support skills • Accept what a mother/parent/caregiver thinks and feels • Recognize and praise what a mother/parent/caregiver and baby are doing well • Give practical help • Give specific, relevant information • Use simple language • Make one or two suggestions, not commands HELPFUL NON-VERBAL COMMUNICATION ▪ Posture: keep your head at the same level as the mother/parent/caregiver ▪ Pay attention and use eye contact ▪ Remove physical barriers ▪ Take time ▪ Use appropriate touch Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 62 THE FOUR KEY POINTS OF POSITIONING 1. Baby’s head and body in line 2. Baby held close to mother’s body 3. Baby’s whole body supported 4. Baby approaches breast, nose to nipple THE FOUR KEY POINTS OF ATTACHMENT 1. More areola seen above baby’s top lip 2. Baby’s mouth open wide 3. Lower lip turned outwards 4. Baby’s chin touches breast Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 63 HELPING A MOTHER POSITION THE BABY ▪ Greet the mother and ask how feeding is going. ▪ Assess a breastfeed first. ▪ Explain what might help and ask whether she would like you to show her. ▪ Make sure that she is comfortable and relaxed. ▪ Sit down yourself in a comfortable, convenient position. ▪ Explain how to hold her baby and show her, if necessary, with a doll. The four key points are: 1. baby’s head and body in line 2. baby held close to mother’s body 3. baby’s whole body supported 4. baby approaches breast, nose to nipple. ▪ Show her how to support her breast only if needed: 1. with her fingers flat against her chest wall below her breast 2. with her first finger supporting the breast 3. with her thumb above 4. her fingers should not be too near the nipple. ▪ Explain or show her how to help the baby to attach: 1. touch her baby's lips with her nipple 2. wait until her baby's mouth is opening wide 3. move her baby quickly onto her breast, aiming the lower lip below the nipple. ▪ Notice how she responds and ask her how her baby's suckling feels. ▪ Look for signs of good attachment. If the attachment is not good, try again. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 64 HOW TO PREPARE A CONTAINER FOR EXPRESSED BREAST MILK ▪ Choose a small cup, jug or jar with a wide mouth. ▪ Wash the cup in soap and water (she can do this the day before). ▪ Pour boiling water into the cup and leave it for a few minutes. Boiling water will kill most of the germs. ▪ When ready to express milk, pour the water out of the cup. ▪ Use a small syringe (without a needle) or a spoon if colostrum is being expressed. If a mother can only express a few drops, it can be difficult to collect in a cup. A helper can collect it with a syringe directly from the nipple and it can be given to the baby directly from the syringe. HOW TO EXPRESS BREAST MILK BY HAND Teach a mother as follows. ● Wash her hands thoroughly. ● Sit or stand comfortably and hold the container near her breast. ● Put her thumb on her breast above the nipple and areola, and her first finger or first two fingers on the breast below the nipple and areola, opposite the thumb. She supports the breast with her other fingers. ● Press her thumb and first finger or first two fingers slightly inwards towards the chest wall. She should avoid pressing too far, or she may block the milk ducts. ● Press her breast behind the nipple and areola between her first finger or first two fingers and thumb. She should press on the larger ducts beneath the areola. Sometimes in a lactating breast, it is possible to feel the ducts. They are like pods, or peanuts. If she can feel them, she can press on them. ● Press and release, press and release. This should not hurt – if it hurts, the technique is wrong. At first no milk may come, but after pressing a few times, milk starts to drip out. It may flow in streams if the oxytocin reflex is active. ▪ Press the areola in the same way from the sides, to make sure that milk is expressed from all segments of the breast. ▪ Avoid rubbing or sliding her fingers along the skin. The movement of the fingers should be more like rolling. ▪ Avoid squeezing close to the nipple press behind it. Pressing or pulling the nipple itself cannot express the milk. It is the same as the baby sucking only the nipple. ▪ Express one breast for at least three to five minutes until the flow slows; then express the other side; and then repeat both sides. She can use either hand for either breast or change when they tire. ▪ Explain that to express breast milk adequately takes 20–30 minutes, especially in the first few days when only a little milk may be produced. It is important not to try to express in a shorter time. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 65 CUP FEEDING A BABY Ask the mother to: ▪ wash her hands; ▪ place the estimated amount of milk for one feed into the cup; ▪ put a cloth on the front of the baby to protect the baby’s clothes from spilled milk: - wrap the baby in a shawl to restrict arm movement to avoid knocking the cup; - hold the baby sitting upright or semi-upright on your lap; - hold the cup of milk to the baby’s lips; - rest the cup lightly on the baby’s lower lip; - touch the edge of the cup to the outer part of the baby’s upper lip; - tip the cup so that the milk just reaches the baby's lips; - do not pour milk into the baby’s mouth – this can cause aspiration; - when babies smell breast milk, they become alert, and open their mouth and eyes – they often put their tongue into the milk to start the feed; - when a term baby is used to cup feeding, they sip or suck the milk; - preterm babies take milk into their mouths with their tongue, using a lapping movement; - preterm babies do not dribble as much as older babies because they have less active tongue movements. ▪ When the baby has had enough, they close their mouth and will not take any more. If the baby has not taken the calculated amount, they may take more next time, or you may need to feed them more often. ▪ It is normal for babies to take different amounts at each feed. Measure the baby’s intake over 24 hours – not just at each feed. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 66 5.4 Demonstration and scripts for role play DEMONSTRATION 3.A – NON-VERBAL COMMUNICATION With each demonstration, say exactly the same few words, and try to say them in the same way, for example: “Good morning, Fatima. How is feeding going for you and your baby?” 1. Posture Help: Sit so that your head is level with hers. Hinder: Stand with your head higher than the mother’s. 2. Eye contact Help: Look at her and pay attention as she speaks. Hinder: Look away at something else, or down at your notes, watch or mobile phone. (Cultural note: What does eye contact look like in your culture and with the mothers/parents/caregivers you are working with? Eye contact may have different meanings in different cultures. Sometimes when a person looks away it means that he or she is ready to listen. If necessary, adapt this to your own situation. 3. Barriers Help: Remove the table or the notes. Hinder: • Sit behind a table • Write notes while you talk • Look at your mobile phone. 4. Taking time Help: Show the mother you have time. Sit down and greet her without hurrying. Stay quietly smiling at her, watching her breastfeed and waiting for her to answer. Hinder: • Be in a hurry • Greet her quickly • Show signs of impatience • Look at your watch or mobile phone. 5. Touch Help: Touch the mother appropriately. Hinder: Touch her in an "inappropriate" way or poke the baby. (Note: If you cannot demonstrate inappropriate touch, simply demonstrate not touching.) Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 67 DEMONSTRATION 3.B – CLOSED QUESTIONS TO WHICH THE MOTHER CAN ANSWER “YES” OR “NO” Health worker: Good morning, (name). I am (name), the midwife. Are you and your baby well today? Mother: Yes, we are well. Health worker: Are you breastfeeding him? Mother: Yes. Health worker: Are you having any difficulties? Mother: No. Health worker: Is he breastfeeding very often? Mother: Yes. Ask: What did the health worker learn from this mother? Comment: The health worker got “yes” and “no” for answers and received less information. It can be difficult to know what to say next. Let us see another way of doing this. DEMONSTRATION 3.C – OPEN QUESTIONS Health worker: Good morning, (name). I am (name), the midwife. How is (baby’s name)? Mother: She is well, and she is very hungry. Health worker: Tell me about how you are feeding her? Mother: She is breastfeeding. I am thinking of giving her a bottle of formula in the evenings. Health worker: What made you think of doing that? Mother: She wants to feed too much at that time, so I thought that my milk is not enough. Ask: What did the health worker learn from this mother? Comment: The health worker asked open questions. The mother could not answer with a “yes” or a “no”, and she gave some information. The health worker learnt much more. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 68 DEMONSTRATION 3.D – USING RESPONSES AND GESTURES SHOWING INTEREST Health worker: Good morning, (name). How is (baby’s name) feeding? Mother: Good morning. She’s fine, I think. Health worker: Mmm… (nods, smiles.) Mother: Well, I was a bit worried last night because she was crying a lot. Health worker: Oh dear! (raises eyebrows, looks interested.) Mother: I wondered if it was because she was in pain after she was born. Health worker: Aha! (nods sympathetically.) Ask: How did the health worker encourage the mother to talk? Comment: The health worker asked a question to start the conversation. Then, she encouraged the mother to continue talking using responses and gestures. DEMONSTRATION 3.E – REFLECTING BACK Health worker: Good morning, (name). How are you and (baby’s name) today? Mother: He wants to feed too much. He is taking my breast all the time! Health worker: Mmm… (Baby’s name) is feeding very often? Mother: Yes, my mother is telling me I should give him some bottle feeds as well. Health worker: Your mother says that he needs something more? Mother: Yes. Which infant formula is best? Ask: What did the health worker learn from the mother? Comment: By reflecting back what the mother said, the mother gave more information. Responses like, “Mmm” show you are listening and following what the mother is saying. Reflecting back can help clarify the person’s statement. We see here the hungry baby may not be the main problem. The comments of the mother’s mother are confusing her. DEMONSTRATION 3.F – SYMPATHY Health worker: Good morning, (name). How are you and (baby’s name) today? Mother: (baby’s name) is not feeding well. I am worried he is ill. Health worker: I understand how you feel. When my child was ill, I was so worried. I know exactly how you feel. Mother: What was wrong with your child? Ask: Do you think the health worker showed sympathy or empathy? Comment: Here the focus moved from the mother to the health worker. This was sympathy, not empathy. Let us hear this again, with the focus on the mother and empathizing with her feelings. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 69 DEMONSTRATION 3.G – EMPATHY Health worker: Good morning, (name). How are you and (baby’s name) today? Mother: He is not feeding well. I am worried he is ill. Health worker: This must be very frightening for you. Ask: Do you think the health worker showed sympathy or empathy? Comment: Here the health worker used the skill of empathy. She said, “This must be very frightening for you”. In this second version, the mother and her feelings are the focus of the conversation. DEMONSTRATION 3.H – USING JUDGING WORDS Health worker: Good morning. Is (baby’s name) breastfeeding normally? Mother: Well – I think so. Health worker: Do you think that you have enough breast milk for him? Mother: I don't know … I hope so, but maybe not ... (she looks worried). Health worker: Well, does she feed properly? Mother: I don't know … Ask: What did the health worker learn about the mother’s feelings? Comment: The health worker has not learnt what she hoped but has instead made the mother very worried. Let us see another way of doing this. DEMONSTRATION 3.I – AVOIDING JUDGING WORDS Health worker: Good morning. How is breastfeeding going for you and (baby’s name)? Mother: It's going very well. I haven’t needed to give her anything else. My baby is eating and sleeping well. I am very pleased. Ask: What did the health worker learn about the mother’s feelings? Comment: This time the health worker learnt what she needed to know without making the mother worried. The health worker used open questions to avoid using judging words. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 70 DEMONSTRATION 3.J – SUMMARY OF SIX LISTENING AND LEARNING SKILLS Health worker: (Skill 2: Open question) Mother: Health worker: (Skill 3) Mother: Health worker: (Skill 4) Mother: Health worker: (Skill 5) Mother: Health worker: (Skill 6) Health worker (with a smile) enters the room, finds a chair, puts her phone in her bag and sets down her clipboard. (Skill 1: Helpful non-verbal). Good morning. How is feeding going for you? He is a little boy isn’t he? How is he? He is doing well. My breasts are full, and he is feeding very often. I am glad that I decided to breastfeed him. Mmmm... (smiles and nods). I was worried last night because he was crying a lot. You were feeling worried because he was crying a lot? Yes, he kept crying and wanted to keep feeding. My family was saying to give him baby formula, but I only want to give him my milk. It’s not surprising you felt worried. You were wanting support to help with breastfeeding your baby! Yes, you understand. Can you help me today? Yes, of course. Can I watch your baby breastfeeding? We can see how he is suckling, and look at your breasts, and then we can talk more about what might help. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 71 DEMONSTRATION 4.A – ACCEPTING WHAT A MOTHER THINKS Mother: I want to give my baby a bottle of formula because I don’t have enough milk for her. Health worker: I am sure your milk is enough. Your baby does not need a bottle of formula. Ask: Did the health worker agree, disagree or accept how the mother feels? Comment: This response disagrees and dismisses what the mother is saying. The health worker is not building the mother's confidence. Mother: I want to give my baby a bottle of formula because I don’t have enough milk for her. Health worker: Yes, a bottle can sometimes settle a baby. Ask: Did the health worker agree, disagree or accept what the mother says? Comment: This response agrees with incorrect information. It is not helpful and may discourage the mother from breastfeeding. Mother: I want to give my baby a bottle of formula because I don’t have enough milk for her. Health worker: I see. You are worried about your milk? Ask: Did the health worker agree, disagree or accept? Comment: This response shows acceptance. The health worker accepts what the mother says and acknowledges her viewpoint. They can now continue to talk about breastfeeding and discuss correct information about milk supply. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 72 DEMONSTRATION 4.B – ACCEPTING HOW A MOTHER FEELS Health worker: Mother (in tears): Good morning (name), how is feeding going for you and (baby’s name)? It is terrible. My baby’s nose is completely blocked, and he can’t breastfeed. He just cries, and I don’t know what to do. Health worker: Don’t worry, your baby is doing very well. Ask: Was this an appropriate response? Comment: This response does not address the mother’s feelings and makes her feel wrong to be upset. Health worker: Mother (in tears): Good morning (name), how is feeding going for you and (baby’s name)? It is terrible. My baby’s nose is completely blocked, and he can’t breastfeed. He just cries, and I don’t know what to do. Health worker: Don’t cry. It’s not serious. (Baby’s name) will soon be better. Ask: Was this an appropriate response? Comment: By saying words like “don’t worry” or “don’t cry,” you may make a mother feel it is wrong to be upset. This can reduce her confidence. Health worker: Mother (in tears): Good morning (name), how is feeding going for you and (baby’s name)? It is terrible. My baby’s nose is completely blocked, and he can’t breastfeed. He just cries, and I don’t know what to do. Health worker: You feel upset about (baby’s name) don’t you? Ask: Was this an appropriate response? Comment: This response showed acceptance of how the mother felt and made her feel that it was alright to be upset. This is the best response in the situation. Note: In this example, empathizing was used to show acceptance. This is an example of using a listening and learning skill to show acceptance. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 73 DEMONSTRATION 4.C – USING SIMPLE LANGUAGE AND PROVIDING RELEVANT INFORMATION Health worker: Good morning (name). How is feeding going for you and your baby? Mother: It’s going okay. I am going to start giving my baby formula because I heard that it protects against infections. Health worker: Breast milk is filled with anti-infective factors and immunoglobulin that provide your baby with protection from viral and bacterial infections. Artificially fed babies get diarrhoea more often, partly because artificial feeds lack anti-infective factors. Artificial feeds are often contaminated with harmful bacteria. If you give your baby breast milk, he will benefit from the anti-infective properties and immunoglobulin secreted through your breast milk. Ask: What did you observe? Comment: The health worker provided too much information. She used words that were unfamiliar and medically focused. DEMONSTRATION 4.D – USING SIMPLE LANGUAGE AND PROVIDING RELEVANT INFORMATION Health worker: Good morning (name). How is feeding going for you and your baby? Mother: It’s going okay. But I am going to start giving my baby formula because I heard that it protects against infections. Health worker: You are wondering about what is best for your baby. I’m glad you have come to talk about it. Your breast milk will help protect your baby from infections, but formula will not. If you feed your baby formula, he will have less protection against illness. Ask: What did you observe this time? Comment: The health worker used simple terms and provided relevant information to the mother. Session 4: Building confidence and giving support Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 74 5.5 Answer sheets Session 3: Listening and learning exercises Exercise 3.A Asking open questions Directions Questions 1 and 2 are “closed” with a “yes” or “no” answer. Write a new “open” question, which requires the mother to tell you more. Example “Closed” question “Open” question Are you breastfeeding your baby? How are you feeding your baby? To answer “Closed” questions Possible “open” questions 1. Does your baby feed often? When does your baby feed? 2. Are you having any feeding problems? How is feeding going? Exercise 3.B Reflect back what the mother/parent/caregiver says Directions Statements 1 and 2 are examples of what mothers may tell you. Underneath each statement are three responses. Mark the response that demonstrates “reflecting back” the statement. Example My mother says I don't have enough milk. a) Do you think you have enough? b) Why does she think that? c) She says you have a low milk supply? To answer 1. It seems my baby does not want to suckle from me. a) He seems to be unable to suckle? b) How long has he been unable to suckle? c) Has he had any bottle feeds? 2. I tried feeding him from a bottle, but he spat it out. a) Why did you try using a bottle? b) He was unable to suck from a bottle? c) Have you tried to use a cup? Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 75 Exercise 3.C Empathizing – showing you understand how the mother/parent/caregiver feels Directions Statements 1 and 2 are examples of what mothers may say. The underlined words in each example show how the mother is feeling. Underneath each statement are three responses that the health worker may give. Choose the response showing the health worker understands how the mother/parent/caregiver feels. Example My baby wants to feed so often at night that I feel exhausted. a. How many times does he feed? b. Does he wake you every night? c. You are really tired with the night feeding? To answer 1. My breast milk looks so thin. I am afraid it is not good. a. That's the foremilk. It always looks rather watery. b. You are worried about how your breast milk looks? c. Well, how much does the baby weigh? 2. I feel there is no milk in my breasts, and my baby is a day old already. a. You are upset because your breast milk has not come in yet? b. Has she started suckling yet? c. It always takes a few days for breast milk to come in. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 76 Exercise 3.D – Avoid judging words Directions Underline the judging word. Then re-write each question to both avoid a judging word and to ask an open question. Example Closed question with judging word. Open question without judging word. Is your baby feeding well? How is your baby feeding? To answer Closed question with judging word. Suggested answers for open question without judging word. 1. Does your baby feed often? When does your baby feed? 2. Are you having any problems with feeding? How is feeding going? Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 77 Session 4: Counselling skills: Building confidence and giving support exercises Exercise 4.A – Accepting what a mother/parent/caregiver thinks and feels Directions Draw a line to link which response: 1) accepts 2) agrees with incorrect information 3) disagrees with the mother’s statement. Example Mother: “I give drinks of water if the day is hot.” Response “That isn’t necessary! Breast milk has enough water.” Agreeing (with incorrect information) “Yes, babies need water in hot weather.” Disagreeing “You feel the baby needs some water if it is hot?” Accepting Directions: Link the answer with the type of response Mother: “My baby has diarrhoea, so I am not breastfeeding until it is gone.” Answer: Type of response “You don’t like to give breast milk now?” Agreeing (with incorrect information) “It is quite safe to breastfeed when he has diarrhoea.” Disagreeing “It is best to stop breastfeeding during diarrhoea.” Accepting Mother: “The first milk is not good, so I will need to wait until it has gone.” Answer: Type of response “First milk is very important for the baby.” Agreeing (with incorrect information) “You think the first milk is not good for the baby.” Disagreeing “It will only be a day or two before the first milk is gone.” Accepting Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 78 Exercise 4.B – Recognize skills and praise a mother/parent/caregiver and baby Directions In stories A and B below, create a response praising mother and/or baby. In your response, you only need to give ONE answer. Example Response A mother had to return to work shortly after her baby was born. She expresses breast milk during the day to give to the baby while she is at work. She continues to breastfeed the baby at night. She is worried that she is not breastfeeding enough. It is good you are continuing to breastfeed your baby at night. Exercise Story A Response A mother of a two-day old baby tells you that she is worried her baby is not getting enough breast milk. Her mother has told her the baby is crying because she is thirsty and needs water. Breast milk is all your baby needs right now. It is good that you are only giving your baby breast milk. Story B Response You are taking care of a new mother and her baby. She tells you she is breastfeeding, but her family said she needs to start giving the baby a bottle right away so that he gets used to it. It is good you are breastfeeding your baby and not using a bottle. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 79 Exercise 4.C – Provide relevant information using simple language Directions Re-write the statement using simple language to help the mother to understand. Example Statement Simple language Colostrum is all your baby needs in the first few days. The first yellowish milk that comes is exactly what your baby needs for the first few days. Exercise Statement Simple language 1. “Exclusive breastfeeding provides all the nutrients that your baby needs for the first six months.” “Breastfeeding alone is all your baby needs for health and growth in the first six months.” 2. “The immunoglobulins in human milk provide your baby with protection from viral and bacterial infections.” “Your milk helps protect your baby from illness.” Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 80 Exercise 4.D – Make one or two suggestions, not commands Directions Re-write each command to a suggestion. Example Command Suggestion “Do not give your baby drinks of water” “Have you thought of giving only your milk?” Exercise Command Suggestion 1. “You must feed your baby more.” “Do you think you could feed your baby more often?” 2. “Do not give any foods to your baby until after six months.” “Most babies don’t need any other foods or water until after six months. Does this sound like something you could try?” Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 81 Session 11: Breast and nipple conditions CASE 1 Mrs G says her breasts are painful, and her right nipple is sore. Her baby is four days old. Both Mrs G’s breasts are swollen, and the skin looks shiny. The nipples are stretched flat. You watch her breastfeeding. Her baby is restless and makes smacking sounds as she tries to suckle. After a few sucks, she pulls away and cries. • What is the diagnosis? (Engorgement.) • What can you say to empathize with Mrs G? (You are very uncomfortable, aren’t you?) • What is the cause of Mrs G’s difficulties? (Her breasts are engorged, her nipples are stretched tight, and her baby cannot attach well. This is also causing her nipple to be sore.) • What practical help can you give Mrs G? (Help her to express some of her milk, by hand or pump, to make the breasts softer. Then help her to attach her baby to her breast better. Suggest that she breastfeeds her as often as she is willing so that she removes more of the milk. She may need to express again until the engorgement has cleared.) CASE 2 Mrs B’s baby was born yesterday. She tried to feed her soon after delivery, but she did not suckle very well. She says her nipples are inverted, and she cannot breastfeed. You examine her breasts, and notice her nipples look flat. You ask Mrs B to use her fingers and to stretch her nipple and areola out. She is able to stretch the nipple out a short way, showing that the nipple and areola are protractile. • What could you say to accept Mrs B's idea about her nipples? (Something like: You feel worried because you think your baby may not be able to breastfeed with your nipples?) • What does it mean for her nipples to be protracile? (Stretchy when pulled with fingers.) • How could you build her confidence? (Give her relevant information. For example: explain if her baby suckles from the breast not the nipple, she stretches the nipple out. She can get the milk if she takes a big mouthful of breast.) • What practical help could you give Mrs B? (Offer to help her to get her baby to take more of her breast into her mouth, that is, to improve the attachment.) Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 82 CASE 3 Mrs C notices a painful swelling in her left breast over the last three days. Her nipple is very sore. The skin of a large part of the breast looks red, and it is hard and extremely tender. Mrs C has a fever and feels too ill to go to work today. She is a teacher in the local primary school. She breastfeeds her baby at night. During the day, she expresses milk to leave for him. She has no difficulty in expressing her milk. She is very busy, and it is difficult for her to find time to express milk or to breastfeed her baby during the day. • What could you say to empathize with Mrs C? (You are having a lot of pain and feeling ill.) • What could you say to build Mrs C’s confidence? (Praise her for breastfeeding her baby at night and expressing milk to leave for him.) • What is the diagnosis? (Mastitis. It is not possible to say if it is infective or non-infective. Her nipple is also cracked and looks as though it may be infected.) • Why do you think that Mrs C has this condition? (She is very busy, and she feeds and expresses in a hurry. There is a long time between feeds during the day.) • How would you treat Mrs C? (Suggest that she takes sick leave for a few days and breastfeeds her baby more often. Help her to get a sick-leave certificate so that she can do this. Ask her about family members and friends who could help her with some of her tasks at home. - She should rest as much as possible. - Give her analgesics (ibuprofen) for a few days. - If the mastitis is not improving by tomorrow, refer her to an appropriate health-care provider for antibiotics. • What could you suggest to prevent the same problem from occurring again? (Discuss the reasons why the condition has occurred. Help her to think of ways to breastfeed her baby more, and to take more time to express her milk, especially during the day.) Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 83 CASE 4 Mrs F’s baby is three months old. She says her nipples are sore. They have been sore on and off since a case of mastitis several weeks ago. The mastitis cleared up after a course of antibiotics. This new pain feels like needles going deep into her breast when her baby suckles. The pain continues between feeds, and her nipples are sometimes itchy. You watch her baby breastfeeding. You can see areola above his mouth but not below. His mouth is wide open, his lower lip is turned back, and his chin is close to the breast. He takes some slow deep sucks and you see him swallow. • What could you say to empathize with Mrs F? (You are having a lot of pain, aren’t you?) • What might be the cause of Mrs F's sore nipples? (Candida infection. Her baby is well attached to her breast.) (Check and treat her baby's mouth and bottom for Candida.) • How would you build Mrs F's confidence? (Possibilities include: - praising the way in which her baby is suckling - giving relevant information and explaining the reason for the sore nipples - referring her to an appropriate health-care provider for treatment - explaining that breastfeeding should be comfortable again after treatment with Nystatin.) Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 84 Session 12: Milk supply challenges CASE 1 1. How can you find the cause of Mrs M’s difficulty? • Listen and learn – to learn about psychological factors, and how she feels. • Assess a breastfeed – assess the baby’s attachment and suckling. • Examine the baby – for alertness, appearance, behaviour, illness or abnormality. • Examine the mother’s breasts – for any breast or nipple conditions. • The baby is poorly attached at the breast, and not suckling effectively. 2. How can you help Mrs M and her baby? Encourage participants to remember their skills for building confidence and giving support might help. Use skills for building confidence and giving support. • Praise her for expressing her colostrum to give to her baby. • Empathize with her that the baby was not given the colostrum – that was very bad! But her breasts already have more colostrum. Expressing her milk while her baby was in the special care unit will also help her milk supply to “come in”. • Explain there is enough milk for her baby. Her nipples are sore because he is not taking enough of the breast into his mouth. Offer to help her to attach him better. • When you are sure that the attachment is better, ensure that the baby seems satisfied after he feeds. • Encourage her to continue breastfeeding, and to feed the baby often and for as long as he is willing to feed to help build up her supply. • Refer her to resources in the community for follow-up and additional support. Mrs M gave birth to her baby boy two days ago. She had a caesarean section. When the baby was delivered, he had a medical complication and was taken to the special care unit for babies. Mrs M had expressed colostrum prior to delivery, but her baby didn’t receive it. Instead, Mrs M’s baby was given bottles of infant formula in the special care unit. When Mrs M and her baby were finally able to be together today, she tried to breastfeed him. Mrs M says she feeds him for a few minutes, but then he cries and is hungry again. When her baby is breastfeeding, her nipples become very sore. When you assess a breastfeed, you see: less areola above the baby’s mouth, and more below, and his chin is not touching the breast. The baby is not ill or abnormal, and Mrs M is healthy. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 85 CASE 2 1. What could you say to accept what Mrs P says about her breast milk? • You think that there is no milk in your breasts? • You are worried about your breast milk? 2. What is the reason why Mrs P doubts her ability to breastfeed? • She lacks confidence, and she lacks knowledge. • Her milk has not “come in” yet – but this is normal. 3. What relevant information would you give her? • Her breasts already have some milk, a special kind called “colostrum”. This is what her baby needs just now. Her baby doesn’t need formula – it will just fill up the baby and she won’t want to suckle at the breast. This will make it more difficult for her baby to be good at breastfeeding. • Explain that if her baby suckles more often, it will help more milk to come in. In a day or two, her breasts will feel full. • A pacifier may interfere with her baby establishing breastfeeding. She may miss the baby’s cues for feeding because the baby is sucking on a pacifier. 4. What practical help could you give Mrs P? • Offer to help her to put her baby to her breast. • Start by showing her how to position the baby and see if she will attach and have a feed. Then explain about feeding cues when her baby shows, by restlessness or mouthing, that she is ready for a feed. Mrs P is 20 years old. Her baby was born yesterday and is very healthy. She has tried to breastfeed twice, but her breasts are still soft. She thinks she has no milk and will not be able to breastfeed. When her baby cries, she puts her to the breast. The baby has suckled at her breasts several times. Her husband has offered to buy her a bottle and some formula. He also tells her a pacifier will stop the baby from crying and plans to bring one to her today. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 86 Session 13: Barriers to breastfeeding EXERCISE 13.A Mrs B delivered a baby by vacuum extraction yesterday. Her baby has a bruise on her head. When Mrs B tries to feed her, she cries loudly and pulls away. Mrs B is very upset and feels breastfeeding will be too difficult for her. You watch her trying to feed her baby, and you notice that her hand is pressing on the bruise. 1. Why does Mrs B’s baby cry loudly and is unable to feed at the breast? The baby has a bruise on their head from the vacuum extraction. The baby is in pain when Mrs B presses her hand on the baby’s bruise. This is causing Mrs B’s baby to cry loudly and have difficulty in feeding at the breast. 2. What could you say to empathize with Mrs B? • A possible response is given below but praise participants if they have an alternative response that empathizes with the mother. • A possible response is: You are really upset, aren’t you? 3. What praise and relevant information could you give to build Mrs B’s confidence? • Praise: It is great that you want to breastfeed your baby. • Relevant information: At the moment, the bruise is making breastfeeding painful for your baby. That is why she is crying and having difficulty to feed at the breast. 4. What practical help could you give to Mrs B? • Offer to help to find a way for Mrs B to hold her baby that is not painful for the baby. • Offer to provide pain relief to the baby if necessary. (But breastfeeding itself helps with pain.) • Encourage skin-to-skin contact for Mrs B and her baby. This can be comforting to Mrs B’s baby and allow the baby to suckle at the breast. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 87 EXERCISE 13.B Mrs M had her baby boy yesterday. She says she has been trying by herself to put her baby to her breast, but he could not attach well, and now he is having difficulty to feed at the breast. She says she will have to bottle feed. A nurse has now come to help Mrs M to attach the baby. The nurse puts the baby to face Mrs M’s breast. The nurse then holds Mrs M’s breast with one hand, and the back of the baby’s head with her other hand. The nurse then tries to push the baby onto the breast. The baby pushes his head back and cries. 1. Why is Mrs M’s baby reluctant to feed at the breast? The baby had difficulty attaching, and Mrs M did not receive help at first. Now a nurse has come to help her, but the nurse’s technique is not good. She is pushing on the back of the baby’s head, which makes the baby want to fight back. 2. What could you say to praise the mother and the nurse? The mother: It is good that you have tried so hard to breastfeed. The nurse: It is good that you are trying to help Mrs M to attach her baby. 3. What would you suggest that the nurse does differently? Suggest that a different technique might help. • Try to guide the mother to position and attach her baby by herself, without touching. • Show her what to do using a doll or a rolled-up towel. • Explain that the mother should support the baby by his shoulders and back, and not by pressing on his head. Pressing on the baby’s head may make feeding more of a challenge for the baby. • If you need to help her to position the baby, put your hand over her hand to guide her – do not hold the baby yourself. 4. What three things could you suggest that Mrs M does? • Do not try to make the baby take the breast any more now. • Let him enjoy skin-to-skin contact, and explore your breast with his mouth, until he is willing to try to suckle. • It would be helpful to express your breast milk to feed him by cup until he suckles. Let me show you how to do it. Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 88 Notes ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………….…… ……………………………………………………………………………………………………………………… …………………………………………………………………………………………………………….………… Baby-friendly Hospital Initiative training course for maternity staff: Director’s guide 89 For more information, please contact: Department of Nutrition and Food Safety World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: nutrition@who.int www.who.int/nutrition