J. E. BRADLEY AND 3. MEME
Breastfeeding Promotion in Kenya: Changes in Health Worker Knowledge, Attitudes and Practices, 1982-89 by Janet E. Bradley*, MA, and Joyce Meme, MSc Ministry of Health, Government of Kenya
Introduction Successful breastfeeding during the first few days after delivery is known to be important in securing effective, long-term lactation. Women are more likely to breastfeed for longer durations, less likely to introduce weaning foods and milk supplements too early, and more likely to develop a good, loving relationship with their babies, if the first few days of breatfeeding prove to be a rewarding and positive experience.1"5 Factors helping to establish lactation in the first few days are early breastfeeding (within 1 hour of birth), constant contact between mother and baby through rooming-in, encouragement of demand feeding, an absence of glucose, water or milk supplements, and supportive care. 1 " 5 In traditional societies, women are guided through these first few days by other women, traditional birth attendants, family, and friends. The process of mothering comes naturally, supported by trusted family members. Breastfeeding in these situations rarely falters. Mothers stay with their babies at all times and allow the baby to suckle on demand. In many parts of the developing world today, an increasing number of women deliver in hospitals, and Acknowledgements This work was supported in part by the Kenya Office of UNICEF. The authors wish to thank the Director and Staff of the Division of Family Health, Ministry of Health, and the Infant Feeding Steering Committee of the Ministry of Health, as well as the International Baby Food Action Network (1BFAN) for participating in this study. We would also like to thank David Alnwick and Per Blomquist of UNICEF for advice and technical support. •Correspondence: Jajiet Bradley, PO Box 39814, Nairobi, Kenya. 228
© Oxford University Press 1992
so turn for advice and support to medical and nursing staff. The role of health workers is, therefore, crucial in helping to make the first days of breastfeeding as positive as possible. However, studies in different parts of the world have shown that health workers lack an understanding of lactation management, and are unwilling to act as breastfeeding promoters. They are, thus, unable to organize hospital routines for assisting the successful establishment of lactation. 6 " 8 Thus, health workers themselves have contributed to the recent decline in breastfeeding which has been observed throughout the world. 4 A study of health worker knowledge, attitudes and practices (KAP) conducted in Kenya in 19826 showed that health workers were generally unable to promote breastfeeding amongst their clients due to a lack of knowledge and motivation. Hospital ward practices were found to be detrimental to the establishment of good breastfeeding. Most hospitals delayed the first feed for more than 5 hours, many kept babies in nurseries (limiting demand feeding), and most supplemented mothers' milk with water, glucose or milk feeds. At that time, breastmilk substitutes were being donated to maternity hospitals by infant formula companies. These substitutes were freely used, often with bottles. Concerned about these findings, the Kenyan government embarked on a multi-faceted programme of breastfeeding promotion. In 1983, Kenya developed a Code of Marketing of Breastmilk Substitutes which effectively banned the free supply of infant formula to Kenyan hospitals. In 1983, 1986, and 1988, the Director of Medical Services directed all hospitals to stop distributing infant formula and to institute practices beneficial to breastfeeding mothers. SpecifiJournal of Tropical Pediatrics
Vol.38
October 1992
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Summary In 1982, a study of health worker knowledge, attitudes and practices with respect to breatfeeding was undertaken in Kenya. A breastfeeding promotion campaign ensued, in which training of health workers was a major component. In 1989, the impact of this campaign was evaluated through a survey examining changes in health worker knowledge, attitudes and practices. The survey showed that considerable improvements in knowledge and substantial improvements in hospital practices have occurred, although none of these could be attributed to any single element of the breastfeeding promotion programme. Particularly undesirable practices which were common in 1982, such as separation of mother and baby, formula feeding and use of bottles have virtually disappeared from Kenyan hospitals. Recommendations regarding future programme directions are made.
J. E BRADLEY AND J. MEME
Methods Two questionnaires were designed: one for hospital policy makers, and one for maternity ward sisters and nurses. Many of the questions were the same as those used in the 1982 study. The questions primarily related to health workers' knowledge, attitudes, and practices with respect to the management of lactation. The questionnaire for policy makers also covered areas of policy and decision-making, which are not the subject of this paper. Interviews were conducted by trained interviewers in 58 hospitals throughout the country. In each hospital, we attempted to interview as hospital policy makers, the district medical officer, medical officer in charge and the hospital matron. In their absence (17 cases), the hospital obstetrician or pediatrician was substituted. One-hundred-and-nine such policy makers were contacted. One-hundred-andseventy-five maternity ward staff were also interviewed. We selected the maternity ward sister on duty and two ward nurses at random in each hospital. In the vast majority of cases, three nurses constituted the total number of nurses on duty at the time of the survey and so all were interviewed. Thirty-five of the facilities surveyed were government, district or provincial hospitals (the remaining six could not be reached), and six were Nairobi City Commission health centres having maternity facilities, selected at random from a total of 10. The remaining 17 were either privately owned facilities or fell under the umbrella of the Catholic Secretariat or the Christian Health Association of Kenya. They were selected randomly from Nairobi (six hospitals) and from six other provinces in Kenya (11 hospitals). The sample was not significantly different to that used in the 1982 study and, as many of the questions asked were identical, comparisons between the two time periods could be made. Journal of Tropical Pediatrics
Vol. 38
October 1992
Results Table 1 compares responses to questions on different aspects of breastfeeding knowledge and attitudes between 1982 and 1989. On all aspects of knowledge, health workers scored considerably higher in 1989 than in 1982. This was true both for policy makers and maternity ward staff. Some aspects of good lactation management, such as early contact, rooming-in, nonuse of bottles and formula, and demand feeding were almost universally endorsed in 1989. However, knowledge of the mechanisms of good lactation, the management of an insufficient milk supply and knowledge about when to give pre-lacteal feeds, although higher than in 1982, was still below standard. These results held for both government and private sectors, although larger hospitals, usually in the private sector, tended to have the least knowledgeable staff. Policy makers and maternity ward staff were equally knowledgeable, although among the nurses, the better qualified (Kenya Registered Nurses) were more knowledgeable than the less qualified (Kenya Enrolled Nurses). Table 2 compares practices in Kenyan maternity facilities between 1982and 1989. Practices,as reported by health workers, have improved dramatically. The use of bottles and formula, and the giving of prelacteal feeds, widespread in 1982, were hardly seen in 1989. Early breastfeeding and rooming-in has replaced the earlier practice of keeping mothers and babies apart for most of their hospital stay. Promotion of breastfeeding One of the findings of the 1982 KAP study was that health workers did not accept breastfeeding promotion as one of their responsibilities. In 1982, only 53 per cent of health workers said that they would advise breastfeeding to an indecisive mother and a further 46 per cent would discuss both breastfeeding and bottle feeding, but not try to influence the mother's decision. In 1989, 83 per cent of health workers were recommending breastfeeding and only 15 per cent discussing both methods of feeding. Early suckling In 1982, only 23 per cent of health workers supported the idea of suckling within an hour of delivery. By 1989, feeding within the first hour was recommended by 71 per cent of health workers. In total, 87 per cent of health workers agreed with breastfeeding within 4 hours of birth, compared with 52 per cent in 1982. It is clear, however, that not all health workers understand why early feeding is important. Only 45 per cent of health workers in 1989 agreed that the sucking reflex after delivery is strong. However, this is an improvement over the 15 per cent of 1982. In 1982, only 14 per cent of health workers reported that babies were being put to the breast in the first hour after birth, and 49 per cent in the first 4 hours. By 1989, practices 229
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cally, the directives recommended early breastfeeding after delivery and full rooming-in, banning the routine use of prelacteal and supplementary feeding, and rearranging hospital routines and timetables to suit mothers and their babies, and not the institutional staff. The Ministry of Health also appointed a senior nutritionist as the national breastfeeding officer. Her role has been to organize training of over 800 health workers from all over the country in breastfeeding promotion and lactation management. Other health workers have been trained at specialist lactation management courses overseas. These efforts have been complemented by non-governmental organizations which have concentrated their efforts on training and counselling of individual mothers. In an attempt to evaluate the success of this campaign, we conducted a survey in late 1989 to assess changes in knowledge, attitudes and practices among health workers in Kenyan maternity facilities.
J E.BRADLEY AND J. MEME
Rooming-in In 1982, only 52 per cent of health workers felt that rooming-in was a good idea (Table 1). Furthermore, 39 per cent felt that mothers and babies should be kept
apart most of the time. By 1989, the issue of rooming-in seemed to have been accepted by nearly all health workers (87 per cent), with only 5 per cent advocating separation day and night. In 1982,66 percent of health workers reported that rooming-in was practised in their hospitals. It was more common in government hospitals (83 per cent) than in private ones (32 per cent). Interestingly, workers in government hospitals felt that there was too much rooming-in. Fifty-three per cent would have preferred the mothers and babies to be kept apart. In the private hospitals, on the other hand, 58 per cent of health workersrecommendedthat rooming-in should be practised. By 1989, 98 per cent of government employees and 67 per cent of private hospital employees reported full rooming-in (averaging 89 per cent overall). Demand feeding
In 1982, only 55 per cent of health workers advocated demand feeding, but by 1989, 81 per cent said that it
TABLE 1
Breastfeeding: knowledge and attitudes of health workers, 1982 and 1989 1989
1982
230
Advocate breastfeeding to new mothers as the feeding method of first choice
53% (159/300)
83% (234/284)
Advocate rooming-in at all times
49% (93/191)
89% (252/284)
Advocate keeping babies and mothers apart most of the time in hospital maternity ward
38% (72/191)
4% (12/284)
Advocate feeding babies within 1 hour of birth
23% (46/198)
69% (196/284)
Advocate feeding babies within 4 hours of birth
52% (104/198)
86% (244/284)
Advocate demand feeding
55% (164/300)
81% (231/284)
Advocate unrestricted suckling
23% (45/194)
69% (121/175)
Advocate prelacteal feeding of babies —give water —give glucose feeds —give other milk
95% (184/194) 4% (8/194) 42% (81/194) 49% (95/194)
40% 10% 24% 6%
(115/284) (28/284) (69/284) (18/284)
Advocate exclusive breastfeeding in the first few days
3% (6/194)
58% (166/284)
Know that breastfed babies feed more frequently than bottlefed babies
36% (108/300)
70% (122/175)
Know about strong sucking reflex straight after delivery
20% (39/194)
45% (79/175)
Advocate introduction of mashed fruit before 3 months
66% (196/300)
14% (24/175)
Advocate introduction of mashed fruit between 3 and 6 months
28% (83/300)
66% (115/175)
Advocate introduction of semi-solid food before 3 months
20% (59/300)
5% (10/175)
Advocate introduction of semi-solid food after 6 months
13% (39/300)
31% (54/175)
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had improved in line with improved knowledge. Now 61 per cent of health workers said that feeding within the first hour was practised and 87 per cent within the first 4 hours. Although levels of knowledge on early suckling were similar in government and private hospitals, we found slightly better practices in government hospitals than in private ones, with 52 per cent of private hospitals practicing early breastfeeding, compared with 65 per cent of government hospitals. It is important to note that several mothers on the ward told us that health workers did not always ensure that early feeding took place even when they said that they did. Many women reported waiting for hours before seeing their babies. Also, many primagravidae had their babies with them, but were waiting to be told when to start breastfeeding.
J. E. BRADLEY AND J. MEME
TABLE 2
Breastfeeding: practices in Kenyan maternity facilities, as reported by health workers, 1982 and 1989 1982
1989
14% (27/195)
6 1 % (107/175)
Practice putting babies on breast within 4 hours of birth
49% (96/195)
87% (153/175)
Practice rooming-in at all times
66% (120/182)
89% (156/175)
Practice keeping babies and mothers apart for most of the time in the maternity ward
30% (54/182)
6% (10/175)
Practice giving prelacteal feeds —give water —give glucose —give milk
93% 1% 38% 54%
(178/193) (1/193) (73/193) (104/193)
48% 10% 24% 14%
(85/175) (18/175) (42/175) (25/175)
Practice the routine use of infant formula
54% (105/195)
3 % (5/175)
Practice the use of bottles
80% (156/195)
5% (8/175)
should be the method of choice. However, there is some question as to whether health workers understand that demand feeding not only means letting the baby suck whenever it wants, but also letting it suck for however long it wants. In 1982, only 23 per cent of health workers felt that babies should be able to suckle for an unlimited time in the first few days. This figure had risen to 69 per cent in 1989. Awareness of the need to stimulate milk production was tested by asking maternity ward staff and policy makers what they would do if a mother with a 1month-old baby came to them complaining of a poor milk supply. In 1982, 79 per cent of MCH clinic staff thought that the appropriate action was to supplement the baby with some other milk or food. Only 17 per cent would have suggested that the mother breastfeed more frequently. In 1989, only 19 per cent advocated some sort of supplementation or replacement and 28 per cent mentioned more frequent suckling as a remedy for the problem. In 1989, much more emphasis was placed on encouraging the mother to eat a better diet (28 per cent) and to drink more fluids (20 per cent). Prelacteal feeds In 1982, maternity ward staff recommended prelacteal feeds (4 per cent advocated the use of water, 42 per cent glucose and 49 per cent milk). A mere 3 per cent advocated exclusive breastfeeding. By 1989, the situation had changed, with 58 per cent of all those interviewed recommending exclusive breastfeeding before full lactation. Interestingly, of those 40 per cent advocating prelacteal feeds in 1989, only 6 per cent recommended milk supplements, with 24 per cent recommending glucose supplements and 10 per cent recommending water. In 1982, health workers stated that 93 per cent of hospitals were giving prelacteal feeds routinely Journal of Tropical Pediatrics
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October 1992
(Table 2), a policy supported by 95 per cent of health workers (Table 1). These feeds were usually milk- or sugar-based. By 1989, the situation had changed in several ways. Less than half the respondents said that prelacteal feeds were being given. However, of the feeds given, the most important were glucose and/or water (not milk). Where milk was being given, private hospitals were more likely to be using artificial milk than the government hospitals, in which cow's milk was more popular. Use of infant formula In 1982, 54 per cent of health workers said they routinely used infant formula in hospitals. Representatives of formula companies were regular visitors to Kenyan hospitals and many mothers left the hospital with a free sample of formula and a bottle. That situation has changed dramatically. Formula is still used in hospitals, but to a limited extent and usually only for special cases, such as orphaned or abandoned babies. In very few places is it used routinely (Table 2). In approximately 57 per cent of institutions, formula is not used at all. The larger district hospitals and the Nairobi private hospitals tend to use formula more liberally. However, we only came across one instance of infant formula being supplied free by a formula company. We asked health workers if they had any contact with formula companies over the previous 3 years and three-quarters replied negatively. However, of the other 25 per cent, most said that the visit had been within the past 6 months, after not having had any contact for several years. Use of bottles Bottles are not fashionable in today's Kenyan hospitals. We found only three hospitals in which bottles were definitely being used (all private facilities) and 231
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Practice putting babies on breast within 1 hour of birth
J. E. BRADLEY AND J. MEME
25Means
Medians
Means
Median
19.4 19.5
20-
18
17
16
g
15 15- 14
17
18
14.4
14 10
S 10
rural
M
1977
rural urban
1979
35 25 29 34 Age of mother
10
1982
11
all
30 Age of mother
1982
12
1989
13
FIG. I. Improvement in breastfeeding duration Kenya, 1977-1989.
three others where a single health worker reported their use. However, in seven hospitals (six of which were private), health workers told us that women could bottle feed if they insisted. No bottles were found in any of the government district hospitals or in Nairobi City Commission facilities. Any substance given to the babies (such as expressed breastmilk) was given by cup. Introduction of complementary foods The Kenyan Ministry of Health recommends that infants be introduced to semi-solid food and fruits between the ages of 4 and 6 months. In 1982, it was found that 66 per cent of maternity ward staff advised giving mashed fruits before 3 months of age, with only 28 per cent advising their introduction between 3 and 6 months (Table 1). In 1989, these figures were 14 and 66 per cent, respectively. Similarly, 20 per cent of health workers in 1982 said that semi-solid foods should be introduced to a baby before the age of 3 months. This figure had fallen to 5 per cent in 1989. Government directives One of the recommendations arising from the 1982 study which has been implemented is the issuance of government directives on infant feeding in health institutions. All of these directives have been sent to district medical officers of health and to the private hospital umbrella organizations. However, less than half of the health workers we interviewed had seen or heard of any of the directives, including the most recent one published in 1988. In any case, awareness of the directives was not correlated statistically with 232
higher levels of knowledge nor with better hospital practices. We found that policy makers receiving directives generally passed them on to the ward sisters and never to individual nurses, nor to doctors working in maternity wards. Policy discussions with workers responsible for implementation were rare. We also found that in some cases health workers had seen directives, but failed to implement them due to a lack of understanding.
Discussion The 1982 KAP study of Kenyan health workers concluded: . . . we found a definite lack of knowledge among health workers. Maternity ward practices were often seen to be not in the best interests of the development of a good production and flow of breast milk, while health workers did not always give the best possible advice to mothers. Many of the recommendations of that study were taken up by the Kenyan Ministry of Health and by NGO's. Senior cadres were trained, as well as maternity ward staff. Directives were issued and a code of marketing for infant formula was gazetted. These efforts have likely contributed to the increase in breastfeeding duration which has been observed in Kenya over the period 1977-89 (Fig. 1). In 1982, health workers displayed low levels of knowledge regarding both the mechanisms of lactation and about their own responsibility for promotJournal of Tropical Pediatrics
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5-
J E.BRADLEY AND J MEME
Journal of Tropical Pediatrics
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October 1992
supporting the improvements which have been realized over the last 8 years. We found that government directives were not widely read. Directives should, therefore, be made more accessible to all health workers, and also to patients and their families. This could be accomplished by producing posters stating five or six major breastfeeding 'do's and don't's' which could be displayed in all maternity wards and clinics. We also found that some health workers have seen directives, but not implemented them because they have not understood them or agreed with them. The directives might be better understood and followed if accompanied by an explanatory leaflet, giving details on implementation issues and clarifying responsibilities. A team approach could be adopted, involving personnel such as paediatricians, (who perhaps do not see themselves as part of the hospital administrative hierarchy), in the policy implementation process. The Ministry of Health has provided great impetus for placing breastfeeding onto the national agenda. National breastfeeding statistics have shown that most Kenyan women breastfeed successfully and for a long time, and that the trend towards declining breastfeeding has been arrested. The improvements which we have observed in health worker knowledge and attitudes and in better hospital practices have likely been responsible in part for this success. However, practices in health institutions must reflect what the health workers increasingly know to be good practice. In part, this might be achieved by changing the emphasis of training courses from 'knowledge' to 'implementation'. Training courses, conducted inhouse, should involve hospital teams and should stress roles in the implementation process. These efforts should continue to be supported by a broadening of the audience for government directives to include the maternity patients. Above all, the Kenya Code of Marketing for Breastmilk Substitutes should be strengthened and enforced to ensure that infant formula never again appears in the maternity wards of Kenya.
References 1. Sosa R, Kennell JH, Klaus M, Urrutia JJ. The effect of early mother-infant contact on breastfeeding, infection and growth. In: Ciba Foundation Symposium No. 45, Breastfeeding and the mother. Elsevier Scientific Publishing Company, 1976; 179-193. 2. Siegel E. Early and extended maternal-infant contact—a critical review. Am J Dis Childh 1982; 136: 251-7. 3. WinikofT B, Castle MA. The influence of health services on infant feeding. In: WinikofT B, Castle MA, Laukaran VH (eds) Feeding infants in four societies. New York: Greenwood Press, 1988; 147-64. 4. WHO/UNICEF. Protecting, promoting and supporting breastfeeding: the special role of maternity services. Geneva: WHO, 1989. 233
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ing breastfeeding. In 1989, we found high levels of knowledge and commitment to breastfeeding amongst staff. All of the practices important for the promotion of breastfeeding were, in general, much improved in 1989 over 1982. Most hospitals practise rooming-in, including the private ones. Demand feeding is largely practised and mothers usually breastfeed for the first time within a few hours of delivery. In government hospitals, prelacteal and supplementary feeds are rarely given, with the exception of some private hospitals in Nairobi and Kisumu and Mombasa. There was some variation in hospital practices. We had initially assumed that poor practices would be attributable to a lack of knowledge on the part of policy makers and maternity ward staff. This, however, was not the case. The knowledge of workers in government and private hospitals differed little, yet the latter scored much worse in terms of practices. This might be explained by consumer demand or hospital perceptions of consumer demand. One example is the assertion by some health workers that middle class women in private hospitals neither want their babies with them nor want to breastfeed during the night. This has implications for the training of health workers. It was difficult to pinpoint any one aspect of the government breastfeeding programme that contributed most to the increased levels of knowledge and awareness. Rather, a combination of several factors seem to have been at work. Health workers who had attended post-experience training courses were found to be much more knowledgeable than those who had not attended. However, this increased knowledge often did not translate into improved practices. Several interpretations of this finding are possible. First, most of the training courses selected only one or two participants from each health facility. It is possible, therefore, that trained individuals might have experienced difficulty in initiating change at their hospital. Secondly, the training courses may have emphasized knowledge at the expense of action plans, leading to inadequate implementation. Furthermore, we found that policy makers do not generally see themselves in charge of maternity ward policy, so training policy makers may not have a great deal of impact. One factor which seems to have had a considerable influence on changing hospital practices is the nonavailability of free infant formula in maternity wards. The infant formula companies gave up their campaign of free distribution of formula after publication of the Kenya Code of Marketing of Breastmilk Substitutes and after several NGO's developed programmes to raise awareness in health institutions. The Kenya Code of Marketing is a voluntary one, but although it covers most aspects of marketing, it carries no penalties for non-compliance. Strengthening of the Code, therefore, is seen as an important element in
J. E. BRADLEY AND J. MEME
5. Lawrence R. Breastfeeding: a guide for the medical profession. St Louis: CV Mosby, 1985. 6. Breastfeeding Information Group. Knowledge, attitudes and practices of health workers in Kenya with respect to breastfeeding. Nairobi, 1982. 7. Anand RK. A programme to promote breastfeeding in an urban hospital in India. In: Jelliffe DB, Jelliffe EFP (eds) Programmes to promote breastfeeding. Oxford: Oxford University Press, 1988; 34-41. 8. Relucio-Clavano N. The Baguio general hospital and medical centre breastfeeding and rooming-in programme. In: Jelliffe DB, Jelliffe EFP. Programmes to
9. 10. 11. 12. 13.
promote breastfeeding. Oxford: Oxford University Press, 1988; 22-29. Government of Kenya. Rural Child Nutrition Survey, 1977. Government of Kenya. 2nd Child Nutrition Survey, 1979. Government of Kenya, Central Bureau of Statistics. Nairobi Infant Feeding Study, 1982. Government of Kenya. 3rd Child Nutrition Survey, 1982. National Council for Population and Development. Kenya Demographic and Health Survey. Nairobi, 1989. Downloaded from http://tropej.oxfordjournals.org/ at Memorial University of Newfoundland on January 23, 2015
234
Journal of Tropical Pediatrics
Vol. 38
October 1992
Breastfeeding Promotion in Kenya: Changes in Health Worker Knowledge, Attitudes and Practices, 1982-89 by Janet E. Bradley*, MA, and Joyce Meme, MSc Ministry of Health, Government of Kenya
Introduction Successful breastfeeding during the first few days after delivery is known to be important in securing effective, long-term lactation. Women are more likely to breastfeed for longer durations, less likely to introduce weaning foods and milk supplements too early, and more likely to develop a good, loving relationship with their babies, if the first few days of breatfeeding prove to be a rewarding and positive experience.1"5 Factors helping to establish lactation in the first few days are early breastfeeding (within 1 hour of birth), constant contact between mother and baby through rooming-in, encouragement of demand feeding, an absence of glucose, water or milk supplements, and supportive care. 1 " 5 In traditional societies, women are guided through these first few days by other women, traditional birth attendants, family, and friends. The process of mothering comes naturally, supported by trusted family members. Breastfeeding in these situations rarely falters. Mothers stay with their babies at all times and allow the baby to suckle on demand. In many parts of the developing world today, an increasing number of women deliver in hospitals, and Acknowledgements This work was supported in part by the Kenya Office of UNICEF. The authors wish to thank the Director and Staff of the Division of Family Health, Ministry of Health, and the Infant Feeding Steering Committee of the Ministry of Health, as well as the International Baby Food Action Network (1BFAN) for participating in this study. We would also like to thank David Alnwick and Per Blomquist of UNICEF for advice and technical support. •Correspondence: Jajiet Bradley, PO Box 39814, Nairobi, Kenya. 228
© Oxford University Press 1992
so turn for advice and support to medical and nursing staff. The role of health workers is, therefore, crucial in helping to make the first days of breastfeeding as positive as possible. However, studies in different parts of the world have shown that health workers lack an understanding of lactation management, and are unwilling to act as breastfeeding promoters. They are, thus, unable to organize hospital routines for assisting the successful establishment of lactation. 6 " 8 Thus, health workers themselves have contributed to the recent decline in breastfeeding which has been observed throughout the world. 4 A study of health worker knowledge, attitudes and practices (KAP) conducted in Kenya in 19826 showed that health workers were generally unable to promote breastfeeding amongst their clients due to a lack of knowledge and motivation. Hospital ward practices were found to be detrimental to the establishment of good breastfeeding. Most hospitals delayed the first feed for more than 5 hours, many kept babies in nurseries (limiting demand feeding), and most supplemented mothers' milk with water, glucose or milk feeds. At that time, breastmilk substitutes were being donated to maternity hospitals by infant formula companies. These substitutes were freely used, often with bottles. Concerned about these findings, the Kenyan government embarked on a multi-faceted programme of breastfeeding promotion. In 1983, Kenya developed a Code of Marketing of Breastmilk Substitutes which effectively banned the free supply of infant formula to Kenyan hospitals. In 1983, 1986, and 1988, the Director of Medical Services directed all hospitals to stop distributing infant formula and to institute practices beneficial to breastfeeding mothers. SpecifiJournal of Tropical Pediatrics
Vol.38
October 1992
Downloaded from http://tropej.oxfordjournals.org/ at Memorial University of Newfoundland on January 23, 2015
Summary In 1982, a study of health worker knowledge, attitudes and practices with respect to breatfeeding was undertaken in Kenya. A breastfeeding promotion campaign ensued, in which training of health workers was a major component. In 1989, the impact of this campaign was evaluated through a survey examining changes in health worker knowledge, attitudes and practices. The survey showed that considerable improvements in knowledge and substantial improvements in hospital practices have occurred, although none of these could be attributed to any single element of the breastfeeding promotion programme. Particularly undesirable practices which were common in 1982, such as separation of mother and baby, formula feeding and use of bottles have virtually disappeared from Kenyan hospitals. Recommendations regarding future programme directions are made.
J. E BRADLEY AND J. MEME
Methods Two questionnaires were designed: one for hospital policy makers, and one for maternity ward sisters and nurses. Many of the questions were the same as those used in the 1982 study. The questions primarily related to health workers' knowledge, attitudes, and practices with respect to the management of lactation. The questionnaire for policy makers also covered areas of policy and decision-making, which are not the subject of this paper. Interviews were conducted by trained interviewers in 58 hospitals throughout the country. In each hospital, we attempted to interview as hospital policy makers, the district medical officer, medical officer in charge and the hospital matron. In their absence (17 cases), the hospital obstetrician or pediatrician was substituted. One-hundred-and-nine such policy makers were contacted. One-hundred-andseventy-five maternity ward staff were also interviewed. We selected the maternity ward sister on duty and two ward nurses at random in each hospital. In the vast majority of cases, three nurses constituted the total number of nurses on duty at the time of the survey and so all were interviewed. Thirty-five of the facilities surveyed were government, district or provincial hospitals (the remaining six could not be reached), and six were Nairobi City Commission health centres having maternity facilities, selected at random from a total of 10. The remaining 17 were either privately owned facilities or fell under the umbrella of the Catholic Secretariat or the Christian Health Association of Kenya. They were selected randomly from Nairobi (six hospitals) and from six other provinces in Kenya (11 hospitals). The sample was not significantly different to that used in the 1982 study and, as many of the questions asked were identical, comparisons between the two time periods could be made. Journal of Tropical Pediatrics
Vol. 38
October 1992
Results Table 1 compares responses to questions on different aspects of breastfeeding knowledge and attitudes between 1982 and 1989. On all aspects of knowledge, health workers scored considerably higher in 1989 than in 1982. This was true both for policy makers and maternity ward staff. Some aspects of good lactation management, such as early contact, rooming-in, nonuse of bottles and formula, and demand feeding were almost universally endorsed in 1989. However, knowledge of the mechanisms of good lactation, the management of an insufficient milk supply and knowledge about when to give pre-lacteal feeds, although higher than in 1982, was still below standard. These results held for both government and private sectors, although larger hospitals, usually in the private sector, tended to have the least knowledgeable staff. Policy makers and maternity ward staff were equally knowledgeable, although among the nurses, the better qualified (Kenya Registered Nurses) were more knowledgeable than the less qualified (Kenya Enrolled Nurses). Table 2 compares practices in Kenyan maternity facilities between 1982and 1989. Practices,as reported by health workers, have improved dramatically. The use of bottles and formula, and the giving of prelacteal feeds, widespread in 1982, were hardly seen in 1989. Early breastfeeding and rooming-in has replaced the earlier practice of keeping mothers and babies apart for most of their hospital stay. Promotion of breastfeeding One of the findings of the 1982 KAP study was that health workers did not accept breastfeeding promotion as one of their responsibilities. In 1982, only 53 per cent of health workers said that they would advise breastfeeding to an indecisive mother and a further 46 per cent would discuss both breastfeeding and bottle feeding, but not try to influence the mother's decision. In 1989, 83 per cent of health workers were recommending breastfeeding and only 15 per cent discussing both methods of feeding. Early suckling In 1982, only 23 per cent of health workers supported the idea of suckling within an hour of delivery. By 1989, feeding within the first hour was recommended by 71 per cent of health workers. In total, 87 per cent of health workers agreed with breastfeeding within 4 hours of birth, compared with 52 per cent in 1982. It is clear, however, that not all health workers understand why early feeding is important. Only 45 per cent of health workers in 1989 agreed that the sucking reflex after delivery is strong. However, this is an improvement over the 15 per cent of 1982. In 1982, only 14 per cent of health workers reported that babies were being put to the breast in the first hour after birth, and 49 per cent in the first 4 hours. By 1989, practices 229
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cally, the directives recommended early breastfeeding after delivery and full rooming-in, banning the routine use of prelacteal and supplementary feeding, and rearranging hospital routines and timetables to suit mothers and their babies, and not the institutional staff. The Ministry of Health also appointed a senior nutritionist as the national breastfeeding officer. Her role has been to organize training of over 800 health workers from all over the country in breastfeeding promotion and lactation management. Other health workers have been trained at specialist lactation management courses overseas. These efforts have been complemented by non-governmental organizations which have concentrated their efforts on training and counselling of individual mothers. In an attempt to evaluate the success of this campaign, we conducted a survey in late 1989 to assess changes in knowledge, attitudes and practices among health workers in Kenyan maternity facilities.
J E.BRADLEY AND J. MEME
Rooming-in In 1982, only 52 per cent of health workers felt that rooming-in was a good idea (Table 1). Furthermore, 39 per cent felt that mothers and babies should be kept
apart most of the time. By 1989, the issue of rooming-in seemed to have been accepted by nearly all health workers (87 per cent), with only 5 per cent advocating separation day and night. In 1982,66 percent of health workers reported that rooming-in was practised in their hospitals. It was more common in government hospitals (83 per cent) than in private ones (32 per cent). Interestingly, workers in government hospitals felt that there was too much rooming-in. Fifty-three per cent would have preferred the mothers and babies to be kept apart. In the private hospitals, on the other hand, 58 per cent of health workersrecommendedthat rooming-in should be practised. By 1989, 98 per cent of government employees and 67 per cent of private hospital employees reported full rooming-in (averaging 89 per cent overall). Demand feeding
In 1982, only 55 per cent of health workers advocated demand feeding, but by 1989, 81 per cent said that it
TABLE 1
Breastfeeding: knowledge and attitudes of health workers, 1982 and 1989 1989
1982
230
Advocate breastfeeding to new mothers as the feeding method of first choice
53% (159/300)
83% (234/284)
Advocate rooming-in at all times
49% (93/191)
89% (252/284)
Advocate keeping babies and mothers apart most of the time in hospital maternity ward
38% (72/191)
4% (12/284)
Advocate feeding babies within 1 hour of birth
23% (46/198)
69% (196/284)
Advocate feeding babies within 4 hours of birth
52% (104/198)
86% (244/284)
Advocate demand feeding
55% (164/300)
81% (231/284)
Advocate unrestricted suckling
23% (45/194)
69% (121/175)
Advocate prelacteal feeding of babies —give water —give glucose feeds —give other milk
95% (184/194) 4% (8/194) 42% (81/194) 49% (95/194)
40% 10% 24% 6%
(115/284) (28/284) (69/284) (18/284)
Advocate exclusive breastfeeding in the first few days
3% (6/194)
58% (166/284)
Know that breastfed babies feed more frequently than bottlefed babies
36% (108/300)
70% (122/175)
Know about strong sucking reflex straight after delivery
20% (39/194)
45% (79/175)
Advocate introduction of mashed fruit before 3 months
66% (196/300)
14% (24/175)
Advocate introduction of mashed fruit between 3 and 6 months
28% (83/300)
66% (115/175)
Advocate introduction of semi-solid food before 3 months
20% (59/300)
5% (10/175)
Advocate introduction of semi-solid food after 6 months
13% (39/300)
31% (54/175)
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had improved in line with improved knowledge. Now 61 per cent of health workers said that feeding within the first hour was practised and 87 per cent within the first 4 hours. Although levels of knowledge on early suckling were similar in government and private hospitals, we found slightly better practices in government hospitals than in private ones, with 52 per cent of private hospitals practicing early breastfeeding, compared with 65 per cent of government hospitals. It is important to note that several mothers on the ward told us that health workers did not always ensure that early feeding took place even when they said that they did. Many women reported waiting for hours before seeing their babies. Also, many primagravidae had their babies with them, but were waiting to be told when to start breastfeeding.
J. E. BRADLEY AND J. MEME
TABLE 2
Breastfeeding: practices in Kenyan maternity facilities, as reported by health workers, 1982 and 1989 1982
1989
14% (27/195)
6 1 % (107/175)
Practice putting babies on breast within 4 hours of birth
49% (96/195)
87% (153/175)
Practice rooming-in at all times
66% (120/182)
89% (156/175)
Practice keeping babies and mothers apart for most of the time in the maternity ward
30% (54/182)
6% (10/175)
Practice giving prelacteal feeds —give water —give glucose —give milk
93% 1% 38% 54%
(178/193) (1/193) (73/193) (104/193)
48% 10% 24% 14%
(85/175) (18/175) (42/175) (25/175)
Practice the routine use of infant formula
54% (105/195)
3 % (5/175)
Practice the use of bottles
80% (156/195)
5% (8/175)
should be the method of choice. However, there is some question as to whether health workers understand that demand feeding not only means letting the baby suck whenever it wants, but also letting it suck for however long it wants. In 1982, only 23 per cent of health workers felt that babies should be able to suckle for an unlimited time in the first few days. This figure had risen to 69 per cent in 1989. Awareness of the need to stimulate milk production was tested by asking maternity ward staff and policy makers what they would do if a mother with a 1month-old baby came to them complaining of a poor milk supply. In 1982, 79 per cent of MCH clinic staff thought that the appropriate action was to supplement the baby with some other milk or food. Only 17 per cent would have suggested that the mother breastfeed more frequently. In 1989, only 19 per cent advocated some sort of supplementation or replacement and 28 per cent mentioned more frequent suckling as a remedy for the problem. In 1989, much more emphasis was placed on encouraging the mother to eat a better diet (28 per cent) and to drink more fluids (20 per cent). Prelacteal feeds In 1982, maternity ward staff recommended prelacteal feeds (4 per cent advocated the use of water, 42 per cent glucose and 49 per cent milk). A mere 3 per cent advocated exclusive breastfeeding. By 1989, the situation had changed, with 58 per cent of all those interviewed recommending exclusive breastfeeding before full lactation. Interestingly, of those 40 per cent advocating prelacteal feeds in 1989, only 6 per cent recommended milk supplements, with 24 per cent recommending glucose supplements and 10 per cent recommending water. In 1982, health workers stated that 93 per cent of hospitals were giving prelacteal feeds routinely Journal of Tropical Pediatrics
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October 1992
(Table 2), a policy supported by 95 per cent of health workers (Table 1). These feeds were usually milk- or sugar-based. By 1989, the situation had changed in several ways. Less than half the respondents said that prelacteal feeds were being given. However, of the feeds given, the most important were glucose and/or water (not milk). Where milk was being given, private hospitals were more likely to be using artificial milk than the government hospitals, in which cow's milk was more popular. Use of infant formula In 1982, 54 per cent of health workers said they routinely used infant formula in hospitals. Representatives of formula companies were regular visitors to Kenyan hospitals and many mothers left the hospital with a free sample of formula and a bottle. That situation has changed dramatically. Formula is still used in hospitals, but to a limited extent and usually only for special cases, such as orphaned or abandoned babies. In very few places is it used routinely (Table 2). In approximately 57 per cent of institutions, formula is not used at all. The larger district hospitals and the Nairobi private hospitals tend to use formula more liberally. However, we only came across one instance of infant formula being supplied free by a formula company. We asked health workers if they had any contact with formula companies over the previous 3 years and three-quarters replied negatively. However, of the other 25 per cent, most said that the visit had been within the past 6 months, after not having had any contact for several years. Use of bottles Bottles are not fashionable in today's Kenyan hospitals. We found only three hospitals in which bottles were definitely being used (all private facilities) and 231
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Practice putting babies on breast within 1 hour of birth
J. E. BRADLEY AND J. MEME
25Means
Medians
Means
Median
19.4 19.5
20-
18
17
16
g
15 15- 14
17
18
14.4
14 10
S 10
rural
M
1977
rural urban
1979
35 25 29 34 Age of mother
10
1982
11
all
30 Age of mother
1982
12
1989
13
FIG. I. Improvement in breastfeeding duration Kenya, 1977-1989.
three others where a single health worker reported their use. However, in seven hospitals (six of which were private), health workers told us that women could bottle feed if they insisted. No bottles were found in any of the government district hospitals or in Nairobi City Commission facilities. Any substance given to the babies (such as expressed breastmilk) was given by cup. Introduction of complementary foods The Kenyan Ministry of Health recommends that infants be introduced to semi-solid food and fruits between the ages of 4 and 6 months. In 1982, it was found that 66 per cent of maternity ward staff advised giving mashed fruits before 3 months of age, with only 28 per cent advising their introduction between 3 and 6 months (Table 1). In 1989, these figures were 14 and 66 per cent, respectively. Similarly, 20 per cent of health workers in 1982 said that semi-solid foods should be introduced to a baby before the age of 3 months. This figure had fallen to 5 per cent in 1989. Government directives One of the recommendations arising from the 1982 study which has been implemented is the issuance of government directives on infant feeding in health institutions. All of these directives have been sent to district medical officers of health and to the private hospital umbrella organizations. However, less than half of the health workers we interviewed had seen or heard of any of the directives, including the most recent one published in 1988. In any case, awareness of the directives was not correlated statistically with 232
higher levels of knowledge nor with better hospital practices. We found that policy makers receiving directives generally passed them on to the ward sisters and never to individual nurses, nor to doctors working in maternity wards. Policy discussions with workers responsible for implementation were rare. We also found that in some cases health workers had seen directives, but failed to implement them due to a lack of understanding.
Discussion The 1982 KAP study of Kenyan health workers concluded: . . . we found a definite lack of knowledge among health workers. Maternity ward practices were often seen to be not in the best interests of the development of a good production and flow of breast milk, while health workers did not always give the best possible advice to mothers. Many of the recommendations of that study were taken up by the Kenyan Ministry of Health and by NGO's. Senior cadres were trained, as well as maternity ward staff. Directives were issued and a code of marketing for infant formula was gazetted. These efforts have likely contributed to the increase in breastfeeding duration which has been observed in Kenya over the period 1977-89 (Fig. 1). In 1982, health workers displayed low levels of knowledge regarding both the mechanisms of lactation and about their own responsibility for promotJournal of Tropical Pediatrics
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5-
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supporting the improvements which have been realized over the last 8 years. We found that government directives were not widely read. Directives should, therefore, be made more accessible to all health workers, and also to patients and their families. This could be accomplished by producing posters stating five or six major breastfeeding 'do's and don't's' which could be displayed in all maternity wards and clinics. We also found that some health workers have seen directives, but not implemented them because they have not understood them or agreed with them. The directives might be better understood and followed if accompanied by an explanatory leaflet, giving details on implementation issues and clarifying responsibilities. A team approach could be adopted, involving personnel such as paediatricians, (who perhaps do not see themselves as part of the hospital administrative hierarchy), in the policy implementation process. The Ministry of Health has provided great impetus for placing breastfeeding onto the national agenda. National breastfeeding statistics have shown that most Kenyan women breastfeed successfully and for a long time, and that the trend towards declining breastfeeding has been arrested. The improvements which we have observed in health worker knowledge and attitudes and in better hospital practices have likely been responsible in part for this success. However, practices in health institutions must reflect what the health workers increasingly know to be good practice. In part, this might be achieved by changing the emphasis of training courses from 'knowledge' to 'implementation'. Training courses, conducted inhouse, should involve hospital teams and should stress roles in the implementation process. These efforts should continue to be supported by a broadening of the audience for government directives to include the maternity patients. Above all, the Kenya Code of Marketing for Breastmilk Substitutes should be strengthened and enforced to ensure that infant formula never again appears in the maternity wards of Kenya.
References 1. Sosa R, Kennell JH, Klaus M, Urrutia JJ. The effect of early mother-infant contact on breastfeeding, infection and growth. In: Ciba Foundation Symposium No. 45, Breastfeeding and the mother. Elsevier Scientific Publishing Company, 1976; 179-193. 2. Siegel E. Early and extended maternal-infant contact—a critical review. Am J Dis Childh 1982; 136: 251-7. 3. WinikofT B, Castle MA. The influence of health services on infant feeding. In: WinikofT B, Castle MA, Laukaran VH (eds) Feeding infants in four societies. New York: Greenwood Press, 1988; 147-64. 4. WHO/UNICEF. Protecting, promoting and supporting breastfeeding: the special role of maternity services. Geneva: WHO, 1989. 233
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ing breastfeeding. In 1989, we found high levels of knowledge and commitment to breastfeeding amongst staff. All of the practices important for the promotion of breastfeeding were, in general, much improved in 1989 over 1982. Most hospitals practise rooming-in, including the private ones. Demand feeding is largely practised and mothers usually breastfeed for the first time within a few hours of delivery. In government hospitals, prelacteal and supplementary feeds are rarely given, with the exception of some private hospitals in Nairobi and Kisumu and Mombasa. There was some variation in hospital practices. We had initially assumed that poor practices would be attributable to a lack of knowledge on the part of policy makers and maternity ward staff. This, however, was not the case. The knowledge of workers in government and private hospitals differed little, yet the latter scored much worse in terms of practices. This might be explained by consumer demand or hospital perceptions of consumer demand. One example is the assertion by some health workers that middle class women in private hospitals neither want their babies with them nor want to breastfeed during the night. This has implications for the training of health workers. It was difficult to pinpoint any one aspect of the government breastfeeding programme that contributed most to the increased levels of knowledge and awareness. Rather, a combination of several factors seem to have been at work. Health workers who had attended post-experience training courses were found to be much more knowledgeable than those who had not attended. However, this increased knowledge often did not translate into improved practices. Several interpretations of this finding are possible. First, most of the training courses selected only one or two participants from each health facility. It is possible, therefore, that trained individuals might have experienced difficulty in initiating change at their hospital. Secondly, the training courses may have emphasized knowledge at the expense of action plans, leading to inadequate implementation. Furthermore, we found that policy makers do not generally see themselves in charge of maternity ward policy, so training policy makers may not have a great deal of impact. One factor which seems to have had a considerable influence on changing hospital practices is the nonavailability of free infant formula in maternity wards. The infant formula companies gave up their campaign of free distribution of formula after publication of the Kenya Code of Marketing of Breastmilk Substitutes and after several NGO's developed programmes to raise awareness in health institutions. The Kenya Code of Marketing is a voluntary one, but although it covers most aspects of marketing, it carries no penalties for non-compliance. Strengthening of the Code, therefore, is seen as an important element in
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5. Lawrence R. Breastfeeding: a guide for the medical profession. St Louis: CV Mosby, 1985. 6. Breastfeeding Information Group. Knowledge, attitudes and practices of health workers in Kenya with respect to breastfeeding. Nairobi, 1982. 7. Anand RK. A programme to promote breastfeeding in an urban hospital in India. In: Jelliffe DB, Jelliffe EFP (eds) Programmes to promote breastfeeding. Oxford: Oxford University Press, 1988; 34-41. 8. Relucio-Clavano N. The Baguio general hospital and medical centre breastfeeding and rooming-in programme. In: Jelliffe DB, Jelliffe EFP. Programmes to
9. 10. 11. 12. 13.
promote breastfeeding. Oxford: Oxford University Press, 1988; 22-29. Government of Kenya. Rural Child Nutrition Survey, 1977. Government of Kenya. 2nd Child Nutrition Survey, 1979. Government of Kenya, Central Bureau of Statistics. Nairobi Infant Feeding Study, 1982. Government of Kenya. 3rd Child Nutrition Survey, 1982. National Council for Population and Development. Kenya Demographic and Health Survey. Nairobi, 1989. Downloaded from http://tropej.oxfordjournals.org/ at Memorial University of Newfoundland on January 23, 2015
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