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1~. J. Gynecol. Obsret., 1990,31 (Suppl. 1): 91-103 International Federation of Gynecology and Obstetrics
Breastfeeding promotion: outreach health workers
training
of mid-level and
H.C. Armstrong Lactation and Training Consultant, IBFAN Africa, P.O. Box 34308, Nairobi (Kenya)
Abstract
The process
The International Baby Food Action Network Africa Regional Office (IBFAN Africa) has given thirteen courses in lactation management to subSaharan health workers. The aims of training, the process of running national courses in collaboration with local organizers, and the content of one- to twoweek courses are described. Available teaching resources include books, abstracts, films and slide sets. Forty topics are suggested for mid-level training, with a sample exercise teaching observation of a breastfeed. A twoweek course leads participants through four stages of attitude change. Obstacles to training are listed and solutions recommended.
Each course is given in collaboration with a local organizer, either a private voluntary organization or a ministry of health. The local organizer defines the need, secures government permission, identifies 25-45 participants, and secures local funding for all in-country expenses. The local organizer also arranges for a venue, accommodation, transport, and teaching facilities. IBFAN pays the cost of bringing in outside trainers if needed, books, visual aids, and any trainers-in-training (TRITs) from other countries. A timetable is worked out jointly between IBFAN and the organizer. TRITs are selected as having potential to run training courses in their own countries. They assist the training team, learning from the inside what is entailed and getting some supervised teaching practice. Typically they already have some knowledge of breastfeeding management which deepens as they attend all sessions, take responsibility for parts of the program, and do extra reading. Besides nurses and midwives, we train community health workers, nutritionists, and Breastfeeding support in lay counselors. Africa cannot be left only to the already overburdened workers in health care facilities. Lay counselors in South Africa [l] and in
Introduction Since 1985, the Africa Regional Office of the International Baby Food Action Network (IBFAN Africa) has trained midwives, nurses, and community health workers in lactation management. We have worked in 13 one- to two-week courses in Kenya, Uganda, Ethiopia, Zambia, Zimbabwe, Swaziland, Mauritius, Botswana, and Liberia, as well as in shorter workshops in Tanzania and Zanzibar. 0020-7292/X-J/$03 SO C%1990 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
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APPROXIMATE
COSTS IN U.S. DOLLARS - LACTATION MANAGEMENT COURSE
Jointly sponsored by MCH Coordinating Office, Government of Ethiopia and IBFAN Africa with local funding from UNICEF Ethiopia Programme, held in Nazret, Ethiopia September 18-29, 1988 (10 working days) IBFAN TRAVEL 1 preplanner, Kenya 2 resource persons, Germany and Kenya 1 TRIT, Zambia 45 participants, Ethiopia (including petrol) 2 drivers, per diems
HONORARIUM 1 resource person, Germany CONSULTING AND COORDINATING SERVICES Consulting Administrative and general costs
RESOURCES Books for participants, and handouts Books and visual aids given MCH offices of 13 regions
2140.00 251.21 2391.21
6169.21
150.00 2ooo.00 11413.00 362.32 2178.74 879.23 27.00 2177.00
14833.29
17010.29
800.00
800.00
2700.00 1538.25 4238.25
4238.25
500.00 300.00 800.00
800.00
STATIONERY AND SECRETARIAL HELP 1 secretary per diems Stationery for participants and secretarial use
MISCELLANEOUS TOTAL
TOTAL
298.00 2690.00 630.00
3778.00 FOOD, ACCOMMODATION 1 preplanner 2 resource persons and I TRIT 45 participants 2 Ethiopian resource persons 8 facilitators (5 attended all sessions) rent of meeting rooms and office childcare
UNICEF/MOH
11793.25
169.08 172.71 341.79
341.79
1207.73
1207.73
18714.02
30567.27
45 Ethiopian participants, 2 Ethiopian resource persons, 5 Ethiopian facilitators, 1 Zambian TRIT, 55 beneficiaries which work out to 5576.74 per person Fig. 1. Costs of typical in-country two-week courses.
the United States [2,3] have been shown to be very effective. In Zambia and Zimbabwe, we provide books and other training costs for community volunteers prepared by La Leche League to run mothers’ support groups. Only Int J Gynecol Obstet 31 (SupplI)
a few can benefit from such an intensive apprenticeship approach, but the training is of unparalleled thoroughness and relevance to the immediate needs of mothers. For most people, locally organized courses
Training of health workers APPROXIMATE
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COSTS IN U.S. DOLLARS - LACTATION MANAGEMENT COURSE
Jointly sponsored by Breastfeeding Advocacy Group of Monrovia, Liberia and IBFAN Africa with local funding from UNICEF Liberia Program, held at Phebe Hospital, Bong County, Liberia September 14-25,1987 (10.5 working days) IBFAN TRAVEL 3 resource persons, Kenya and Uganda 2 TRITS, Ghana 1 participant, Sierra Leone 35 participants, Liberia
UNICEF/BAG
TOTAL
2845.00 2845.00
878.65 878.65
3723.65
FOOD, ACCOMMODATION 3 resource persons and 2 TRITS 1 participant, Sierra Leone 35 participants, Liberia
3270.00 655.00 3925.00
7320.00 7320.00
11245.00
HONORARIUM 1 resource person, Uganda
1250.00
1250.00
3200.00 1797.30 4997.30
4997.30
CONSULTING AND COORDINATING SERVICES Consulting Administrative and general costs
RESOURCES Books for participants, visual aids Overweight luggage payment for books Photocopying articles for participants
STATIONERY AND SECRETARIAL SERVICES
600.00 107.00
707.00
118.40 118.40
825.40
55.00
210.00
265.00
123.05
123.05
8650.10
22429.40
MISCELLANEOUS TOTALS
13779.30
35 Liberian participants, 1 Sierra Leone participant, 2 Ghanaian TRITS, 38 beneficiaries which works out to $596.25 per person. Fig. 1. (Continued).
are the most feasible training method. We feel that unless people from the country itself play an active role in organizing and following up on a course, its impact is likely to be minimal. Advantages of training nationals in their own country National courses can be adapted to the country’s needs and conditions. Discussions of nutrition and family planning, epi-
demiological studies, and national policies are possible when all participants come from a single country. The realism of a national course cannot be matched by one elsewhere, which may take place in circumstances not resembling those at home. Small group discussions, role plays, and hospital field work carried out in African languages promote enthusiastic full participation. We have noted that counseling skills learned in one language do not necessarily get applied in another; hence counseling practice Health carepractices related to breastfeeding
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in the actual language of daily work is most beneficial. The training team consists of nationals and outside trainers. Resource people selected from among the country’s medical and nutri-
tion specialists have chances to meet trainers, pick up information as they sit in on other sessions, and become sensitized to the recent significant changes in lactation knowledge. Importing resource people is dramatically
The aim of this form is to help you to learn how to observe a breastfeed. It does not diagnose every breastfeeding difficulty, but helps to select mothers who need more careful attention. Items in brackets apply only to the newborn, not to the older baby. If wished, a score of ten may be arrived at by scoring sections B, R, E, A, and S with 2, 1, or 0, in a manner similar to Apgar scoring. Lines are provided for tick marks next to specific items. If all ticks are in the left hand column, score 2 for that section. If all are in the right hand column, score 0. If they are scattered, use your judgment. If in doubt, give a lower score. The time spent in actual breastfeeding is an important observation, especially if the mother tends to terminate every feed in less than three or four minutes. Babies given very abbreviated feeds may lack the fat-rich hind milk, and get more lactose-containing fore milk than they can easily digest. Some mothers also will terminate feeds before their milk ejection reflex has got well started. Provide followup, including history taking and suck assessment, to any baby and mother who score rather low on this observation, or if the baby is not gaining weight adequately. BODY POSITION - trunk-to-trunk - baby facing breast - head and body aligned [arm position?] - chin on breast - Ibottom supported]
-
body distant from mother’s drooping or off to one side curled or twisted chin away from breast - [only shoulders or head supported]
RESPONSES -
Irooting reflex1 [homing-in responses1 reaches for breast when hungry calm and alert at breast signs of milk ejection reflex in mother
EMOTIONAL BONDING - en face attention from mother - much touching
- [no rooting] - [no homing-in] - no response to breast when hungry - restless or fussy at breast, slips off - no signs of ejection reflex
- no eye contact - minimal touch - nervous, shaking, or limp hold
- secure hold ANATOMY
- breast engorged - nipples flattened, inverted - nipple pain or fissures
- breasts soft - nipples protractile - no nipple pain or fissure SUCKLING - mouth wide open - rhythmic burst-pause sucking/swallowing - tongue visible, cupped - cheeks plump TIME spent actually suckling _ Fig. 2.
Observation of breastfeeds.
Int JGynecol Obstet 31 (Suppl I)
minutes
-
mouth pursed or lax fluttering or clicking sucking tongue not visible cheeks tense or drawn in
Total score.._/I0
Training of health workers
cheaper than sending even a handful of trainees out of their country. Our two-week Liberian and Ethiopian courses worked out at under US$600 per participant, including all local and IBFAN expenditures (Fig. 1). Although in any course there will be a few who did not take much in, a larger number of informed and energized people can be generated by in-country training than by selecting a few to send out. And among the number, there will almost certainly be some who go on actively to apply what they have learned. Mid-level training Many health workers lack up-to-date information on lactation, the ability to diagnose and resolve breastfeeding problems, and the counseling skills which would empower the mother to breastfeed successfully [4--61, In all countries, we have found early signals of breastfeeding failure ignored by health staff, although later they must deal with the major difficulties eventuating from untreated earlier problems. But African health workers do not have time for one-to-one counseling of every mother. We teach trainees to spot the particular women who definitely need focused help, using clues such as observation of a breastfeed (Fig. 2) or growth faltering before 4 months. In addition, since health workers have been trained primarily in a negative approach - to look for problems, to criticize and correct, and to tell women what to do - they may need to learn how to recognize and reinforce good health practices. For instance, few health workers customarily encourage a mother who is breastfeeding a one-year-old to continue for another year. They are more likely to wait for the toddler to develop weanling diarrhea or malnutrition, and then demand of the mother “Why aren’t you breastfeeding?” IBFAN courses aim to overcome some deficits among mid-level health workers: - unquestioning acceptance of customs, whether traditional or medical;
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negative attitudes due to their own past breastfeeding history; a lecturing rather than supportive approach to mothers; out-of-date information on lactation management; - lack of understanding about the formation of national policies, including Codes of Marketing of Breast-milk Substitutes and about proceses of change; and - lack of practical experience in preventing, diagnosing, and overcoming breastfeeding problems. In 1986, IBFAN Africa held a meeting of trainers from seven countries specifically to develop ideas on the content of mid-level health worker training. Their suggestions were written up into a training outline which has been field tested during 1987 and 1988. A final outline giving lesson plans for forty topics (Fig. 3) is now being developed. The whole list is clearly impossible to cover in one short course. Organizers are asked to analyze the needs of their participants, and to select the most relevant topics. They also add topics in accord with national priorities. Yet regardless of how careful the timetabling, participants end every course by saying, “We needed more time. Please add another week.” Stages of change during a course One obstacle to be overcome in each country is the reluctance of administrators to release health workers for even two weeks’ training. Often they ask us just to give a oneto two-day “awareness” workshop, believing that health workers only need greater motivation to promote breastfeeding. We encourage them to compare our modest request with the length of time usually given to family planning courses: four to six weeks. To learn modern breastfeeding management and unlearn established patterns is at least as complex. A single day or two cannot counter years of internalized misinformation and a habitual recourse to bottles. Health workers’ natural resistance to Health care
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INFANT FEEDING IN THE NATIONAL CONTEXT 1. Why is braastfaeding integral to child survival strategies? 2. Traditional patterns and current national trends in infant feeding 3. National food and health issues 4. National policies affecting infant feeding 5. Commercial practices in the country
LACTATION MANAGEMENT 6. Anatomy and physiology 7. Biochemistry and immunology 8. Antenatal preparation and giving birth 9. The first breastfeeds 10. Nipple pain and positioning 11. Breast problems and expression techniques 12. Not enough milk and relactation 13. Sick and low birth weight babies 14. Special situations 15. The working mother 16. Maternal nutrition during lactation 17. Sucking problems and refusing the breast 18. The ideal breastfeeding duration: value of breastmilk during the second year 19. Growth of the baby and young child 20. Foods and feeding during the weaning interval 21. Breastfeeding and child spacing 22. Drugs and breastfeeding 23. Breastfeeding management during illness in mother or baby
COUNSELLING (working with an individual mother) 24. Observation of brestfeeding 25. Psychological factors in breastfeeding 26. Listening and learning from mothers - facts and feelings 27. Taking a history; making a diagnosis 28. Acceptance and support; building a mother’s confidence 29. Running a mother support group
HEALTH EDUCATION (working with groups and communities) 30. Communication skills 31. Choosing who needs to know what: targets and messages 32. Leading group education: alternatives to the lecture method 33. Reeducating health workers and policy makers 34. Using mass media 35. The stages of change in ourselves and colleagues 36. Resources for continuing self-education
ACTION FOR NATIONAL POLICIES TO PROMOTE BREASTFEEDING 37. What is the International Code of Marketing? 38. Implementing the Code and closing loopholes 39. Code monitoring and health worker’s responsibilities 40. Recommendations for a national plan
Fig. 3.
IBFAN
Africa
topics
Int J Gynecol Obstet 31 (Suppi I)
for mid-level
health
worker
training.
Training of health workers
change should not be underestimated. Someone who has run a nursery for 15 years, bottle feeding every baby “until the mother’s milk comes in”, cannot immediately jettison her belief in the need for this routine. Immediate skin-to-skin breastfeeding contact and postpartum comes as a shocking new idea to midwives trained to wrap the newborn right away, separate it from the mother so both can “rest”, and give it a complete bath before it is taken to the mother hours later. It takes time for the possibility of different management to become acceptable. There is another ingredient in resistance. Personal breastfeeding experiences, many of them negative, must be recognized so that retraining can start. Most health workers now practicing did not themselves give four to six months of exclusive breastfeeding, or nurse through their child’s second year. In particular, those who are now old enough to be in leadership positions were in a generation which was influenced in the direction of artificial feeds by the absence of any information save that generated by commercial interests. These parents have an emotional stake in believing that their children did not suffer in any way from bottle feeding. They need to be reassured that they are good parents, that like all of us they did the best they could according to what they knew at the time. Only then are they ready to start accepting new ideas, looking for what might have gone wrong in their own case, and forgiving themselves for any mistakes. They become ready to analyze what influenced them, and prepared to help others avoid the same pitfalls. If they are not given time for this change, they will simply hold to their belief, based on disappointing personal experience, that breastfeeding while ideal in theory just doesn’t work out in practice. There are recognizable stages in the process of change during a course: (1) Ennui. People wonder why the course is needed. Breastfeeding after all is natural, much preached about. widely practiced,
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There really is no problem, so why bother with a course? (A one-day workshop rarely gets beyond this stage). (2) Resistance. If enough new information is discussed during the first two days, by the second or third day there should be some kind of resistance, as participants see the challenge to their established routines. Argument, denial, and some anger may be expected, expressed in culturally appropriate ways. Participants will also start listing problems, without solutions, and assigning blame: “The mothers are careless.. .The doctors expect us to use formula....The government doesn’t give enough maternity leave.. , .We have too many patients. . ..A11 our patients breastfeed in the hospital so it must be the fault of the maternal and child health (MCH) clinics...“. (A two or three day workshop will end at this inopportune moment, just when negativism and confusion have become strongest [7].) (3) Absorption. From the fourth day onwards, the atmosphere tends to change. Participants begin to warm up to the topic and to each other. They talk more freely of their own experiences, both personal and clinical, they look for solutions to problems, they read with more energy, and discuss breastfeeding topics in free time. Field trips at this time are rewarding, as participants talk at length with mothers and notice aspects of breastfeeding previously unremarked. (4) Looking forward. Towards the end of the course, participants focus on needed changes: how they might persuade colleagues; what health education materials they need; what national initiatives are required and how they might be brought about. It is helpful to discuss processes of change so participants will not expect radical conversions overnight. Constructive and cooperative planning of action without the element of blame is possible at this stage. A strong argument for courses of at least two weeks is that transforming one’s attitudes - towards mothers, breastfeeding, oneself,
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and change itself - is difficult and can be painful. It cannot effectively be compressed into a couple of days. Outcome and evaluation Our courses are part of a whole process of networking, helping groups to form and encouraging them to analyze local needs, to develop programs of counseling, Code advocacy, or publications, to undertake informal surveys, and to seek funding. We prefer not to run a course where there is as yet no group to do advance work and follow-up. Thus it is hard to assess the impact of an IBFAN course in isolation. However we are convinced that training is the basis for changes which will be sustained, and that it stimulates further serious attention to breastfeeding in any country. We get positive feedback from every course, and most participants show marked improvement on a post-test compared to a pre-test. Though we have no systematic evaluation thereafter, continuing correspondence with organizing groups indicates diverse outcomes: transformation of a maternity unit in Zambia; vernacular radio programs in Liberia; formation of a vigorous national Code committee in Ghana; development of community counseling services in Mauritius; elimination of bottles from government hospitals in Kenya. We cannot say that one course was the sole factor in a change - it may have been a catalyst or one ingredient in a complex reaction. A 1988 evaluation of the entire IBFAN Africa program, which includes other activities as well as training, concluded: The networks view IBFAN’s training programs as successful, impressive, and participatory. In their view the course structure is comprehensive....A lot of good planning goes into the program....The networks further express the view that training people to train others is IBFAN’s most outstanding effort [8].
Local organizing groups and funding donors both seem convinced that our courses have been worth the effort and the money.
Int J Gynecol Obstet 31 (Suppl I)
Resources Many training workshops provide no books; instead they give diverse handouts including mimeographed notes of sessions. We find that these simply gather dust afterwards, having no indexes, bindings or any particular order. We therefore provide textbooks for every participant to study, to show colleagues later, and to refer back to. For mid-level health workers we use F. Savage King’s Helping Mothers to Breastfeed [9] and IBFAN’s Protecting Infant Health [lo]. A library of additional reference books is available throughout the course, and is left with the local organizing group to fuel further self-education. Duplicated handouts are distributed with supplemental national information, such as health, nutrition, and cultural studies. Additional helpful materials have been the newsletters Mothers and Children [ 1l] and Dialogue on Diarrhoea [ 121 and the visual aids produced by Teaching Aids at Low Cost [ 131. We give out selected photocopied articles provided from our files and also from the Clearinghouse on Infant Feeding and Maternal Nutrition [ 141. The methodology resource Helping Health Workers Learn [ 151 is invaluable, as are slides and films by United Nations Children’s Fund (UNICEF), including our joint videotape Feeding Low Birth Weight Babies [ 161. Caution is needed with visual aids. Quite apart from the likely absence of electricity, room-darkening curtains, and a projector, sessions based primarily on prepared transparencies and slides are not vivid enough. It works better to use a blackboard or flip chart to write down key words and phrases as discussion proceeds. Course participants thrive on eye contact, on give-and-take, and on realistic presentations including brief role plays, demonstrations, and pair practice. Charts and graphs can be helpful to illustrate specific points, but participants may lack experience in drawing practical management
Training of health workers
conclusions froin a mass of data. Slides are a useful adjunct to, but not a substitute for, work with real mothers through clinic visits. Obstacles to training programs “There is no problem” thinking Immersed in more dramatic problems, both national and international officials can easily assume that breastfeeding is one thing they do not have to worry about, particularly if they mistake breastfeeding starts (the “ever breastfed” figure) for a degree of breastfeeding which ensures better health. They may be unfamiliar with the health, nutrition, and child spacing implications of breastfeeding declines. Recommendation: Persuade policymakers that breastfeeding requires attention by demonstrating the relevance of studies done elsewhere. Avoid if possible the delays and expense of tediously replicating basic work in every country. Acceptance of breastfeeding failures Lactation management now tends to be ignored as was the field of obstetrics two hundred years ago, when childbirth was seen as of no particular scientific interest, and a certain wastage of mothers and children was regarded as inevitable. Medical schools still training in the give no specialized multidisciplinary field of breastfeeding. Policymakers may still accept the infant wastage resulting from minimal or no breastfeeding by millions of women, because they have not realized that breastfeeding failures are in large part preventable and may be iatrogenic. Recommendation: Recognize that breastfeeding failures indicate a need for urgent policy action, and that better breastfeeding practices will pay off in better health, nutrition, and child spacing. Commercial influences on policymakers Manufacturers continue to transmit information to policymakers indicating that many women cannot breastfeed, and bottles of
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commercial formula are the only alternative. The manufacturers’ list of situations in which formula will be required includes an enorill, teenage, range: employed, mous undernourished, overworked, and reluctant women; and premature, sick, handicapped, hospitalized, very big, very small, and slowgrowing babies and even, ironically enough, babies possibly allergic to cow’s milk, and babies suffering from diarrhea caused by bottle feeding. These categories usually take in most of the families in any country. Even health workers have allowed choices to become narrowed down to a simple dichotomy, the breast or the bottle of formula. Those unversed in lactation management accept such persuasive “professional information”, which subtly provokes many doubts about breastfeeding, as a basis for public policy decisions. Too often, the most readily available money for breastfeeding research and for conferences on lactation also comes from sources whose primary interest in breastfeeding is as a brief prelude or an accompaniment to feeding with commercial products. Objective scientific information is not reaching key people. Recommendation: Information provided to health professionals or to policymakers from commercial sources should be, in accord with the International Code of Marketing of Breast-milk Substitutes, strictly scientific and factual. Public funding is needed to ensure that professionals can undertake and report research free of distorting factors. Restraints on other forms of commercial influence upon health policymakers should be considered at the national level. Confusion of description with action Numerous countries limit their breastfeeding program to studies of what is happening, and follow with no intervention. Sometimes the studies are repeated at five or ten year intervals, with no protection, promotion, or support during the interval. Recommendation: Specific action programs
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should ensue from any study which documents a decline in breastfeeding. Confusion of custom with what is best Traditional breastfeeding practices may not be ideal for health. Colostrum is widely denied to newborns, and watery additional fluids have acquired the force of custom in many communities. An abrupt cessation of breastfeeding may be counseled following any 24-hour interruption in breastfeeding, a return to sexual relations, or as soon as a new pregnancy is suspected. Such deeply embedded customs may be valuable or may be detrimental to breastfeeding; analysis is needed. Custom cannot be allowed to justify perpetuation of truly harmful practices. Recommendation: Avoid simplistic romanticism about infant feeding traditions, and aim to change those not in the best interest of babies. The myth of integration Integration of breastfeeding into all child survival strategies is an excellent theory, yet so far has tended to make breastfeeding virtually invisible and unfunded. Many programs incorporate a “breastfeeding component”, which scrutiny may reveal is limited to simple exhortations to breastfeed, a limited-distribution pamphlet, or a poster. In too many programs, emphasis, funds, training, and supervision are concentrated upon Expanded Programs on Immunization (EPI), oral rehydration therapy (ORT), family plan- ’ ning, growth monitoring, and programs which stress soft foods whilst failing to encourage continued substantial breastfeeding. A look at any nation’s expenditure on family planning and on breastfeeding respectively is usually illuminating, as is a look at the time use of health workers in “integrated” programs. Breastfeeding support may be overlooked at the clinic level, at the district planning level, and in national budgeting. Ideally lactation goes on much longer than a pregnancy. However, it is far more subject Int J Gynecoi Obstet 31 (Suppl I)
to disruption by cultural beliefs and by mismanagement. Bad advice, worry, and doubt do not cross the placenta, but cause thousands of breastfeeding failures. Integration of breastfeeding into health worker training has so far, however, reflected traditional disproportion: weeks spent on pregnancy, perhaps half a day spent on lactation. Recommendation: First provide specialized training in breastfeeding, to counteract past omissions. Then integrate breastfeeding into all programs and training activities, giving it emphasis, time, and funding consonant with its complexity and its central importance to child survival. The myth that any doctor can talk about breastfeeding A few of the resource persons who are chosen by local organizers to address our courses exemplify the the failure to recognize lactation as a specialist field, by giving lectures based on outdated or very approximate knowledge. On occasion, an obstetrician who has seldom looked above the fundus or beyond the six week checkup is brought in to speak about the whole course of breastfeeding. Non-specialist doctors have also been used by both national and international agencies to write or approve breastfeeding publications and programs, with embarrassing inadequacies in consequence. Recommendation: Recognize lactation management as a specialized field where both recent knowledge and clinical experience are necessary qualifications for teaching or writing. Confusion of institutional changes with ongoing support Even for the minority of African babies born in hospitals or health centers, contacts with any health facility are few, perhaps 12 days in two years of breastfeeding. A woman worried about her baby during the other 718 days of lactation will turn to relatives and friends, or the village health agent. The
Training of health workers
general level of knowledge in her support network must be good. Focusing exclusively on changing practices in health institutions may not alter dangerous community-based patterns of early addition of non-breast milk drinks and foods or abbreviation of breastfeeding. Recommendation: Ensure through public health education that ongoing support at the community level is part of every breastfeeding promotion campaign. Absence of explicit recommendations Neither health workers nor mothers are as yet receiving clear guidance from their health authorities on just how much and how long to breastfeed. Neither training nor other breastfeeding promotion strategies can be effective without explicit recommendations. This is especially important where, as in many African countries, mothers are lessening the intensity and abbreviating the duration of breastfeeding. The vague phrases “as much as possible”, or “as long as you can” leave health workers and parents with the sense that neither exclusiveness nor duration are of much significance. In contrast, other feeding messages are very specific - five meals a day at 18 months, 1100 kcal per day, 20 g of protein, and the like. Nations and agencies should not hold back from establishing clear breastfeeding goals because not all women can or will follow them. Such a reservation could apply to all feeding recommendations. We urge so many meals per day, so much protein and energy food, knowing very well that some children will not get them. It is our responsibility to define what is best for the child, and then see what programs we can implement to ensure that those needs are met, for the children of every nation. UNICEF has taken an international lead by stipulating a pattern: exclusive breastfeeding for four to six months [17]. Parents also need to know how long to go on breastfeeding, with the understanding that breastfeeding can well be continued longer but should
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not be stopped earlier than the target age, perhaps 18 months or 2 years. Recommendation: National and international agencies should set targets for the guidance of mothers and health workers, stipulating the ideal length of exclusive breastfeeding, and the recommended minimum duration. Lack of funding Because breast milk does not appear in most economic reckonings, its value has usually been overlooked. Although the monetary value of breastfeeding is now being proven by the costs of its erosion, most countries as yet provide no funds for its preservation. Without money for training, publications, research, social marketing, office costs, transport, and, even more importantly, without full time salaries for breastfeeding specialists, breastfeeding will not flourish. Yet we can name only one civil servant in the whole subSaharan continent, and less than ten counselors working with non-governmental organizations, who at present receive full time salaries for breastfeeding promotion. This is not to say that only salaried professionals are qualified to give breastfeeding help; it has always been and should remain part of ordinary women’s special province. Nevertheless, we need professionals to reinforce mothers’ experience with research, publications, training, and sound medical advice. Recommendation: Establish salaried full time positions with adequate program budgets for lactation specialists. Shortage of trainers Related to the absence of salaries and of specialized advanced courses is a dearth of qualified trainers. Those used by IBFAN and most national programs are earning their living from some other role, and can spare little time for breastfeeding work. Yet good trainers are rare. They need three qualifications: sound lactation knowledge, wide clinical experience with mothers, and a flexible nonHealth care practices related to breastfeeding
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authoritarian teaching style. At present, the world’s specialists in lactation are largely selfeducated in the field. But in Africa, self-education by health professionals is greatly inhibited by very heavy clinical responsibilities, and by inaccessibility of journals and books. A recently developed examination, set annually by the International Board of Lactation Consultant Examiners [18] tests some aspects of breastfeeding knowledge and may be helpful in identifying competent trainers. However, it does not measure skills in working directly with mothers, nor in teaching. Our TRIT program attempts to prepare Africans to take on more substantial training roles, but is far too cursory to make expert trainers out of people to whom the field is relatively new. We encourage subsaharan countries to send teams to the San Diego Wellstart program, a groundbreaking effort giving both international experience and a month’s concentrated learning to senior medical workers [19]. However, even this pioneering program is too brief; six months or more would be preferable. Recommendation: The effect of courses is minimized when graduates are poorly deployed and absorbed into general medical functions, as has happened with some African Wellstart graduates. A national commitment and budgetary provision to employ the participant afterwards in training others should accompany enrollment in a lactation specialist course. Lack of resources in non-English languages Although we now have some good training materials in English, there is little in other international languages. We do not have in French or Spanish professional-level referenced medical textbooks equivalent to those in English by Lawrence [20] and by Neville and Neifert [21]. Simple, non-referenced publications, such as Helping Mothers to Breastfeed, Protecting Infant Health, and Mothers and Children are fortunately available or forthcoming in Spanish, French, and Int J Gynecol Obstet 31 (Suppl I)
sometimes other international languages. But trainers need more substantial reference works. Slide sets, videotapes, and films also require translation. So far, the rapid expansion of knowledge about breastfeeding management has bypassed far too many language communities. Recommendation: Urgent action is needed to provide substantial professional resources for trainers in French, Spanish, Arabic, and Portuguese, including abstracts similar to Breastfeeding Abstracts [22] and Breastfeeding Briefs [23]. The World Health Organization (WHO) has a role to play in ensuring that its technical documents on infant feeding are published in all United Nations languages. Getting the right people into training Too often the participants invited by the organizers are not released, while others of questionable suitability are sent to replace them. Inappropriate participants are a pervasive problem of all health training, not only of breastfeeding courses, and they alter the atmosphere and effect of any course. Recommendation: Emphasize selection of key people, and give incentives if necessary to encourage their attendance. In a single village clinic, one can usually find some mothers with malnourished children, and other mothers from the same milieu with very healthy children. We have not yet made adequate use of the successful village mothers, training them to reassure and advise their neighbors. Yet the best counselor for a breastfeeding mother with ordinary perplexities is likely to be her peer who is near at hand. Recommendation: Do more to provide training and recognition of lay breastfeeding cormselors at the village level. Providing enough practice with real mothers Only an apprenticeship training gives adequate experience with mothers under favorable conditions. With a group of 25 or more in a course, the trainers have difficulty getting round to see each participant with a mother
Training of health workers
even once during a hospital field trip. Language difficulties may frustrate communication, especially where participants in a nationwide course do not share the vernacular used locally. Mothers can also feel overwhelmed and intimidated by a large number of trainees craning to see how their babies suck. Recommendation: Once salaried breastfeeding specialists are available at the country level, they should provide follow-up to courses by giving participants one-to-one clinical training with mothers .
5
6
7
8
9
Conclusion 10
IBFAN Africa’s experience with training of mid-level health workers has been both The ready gratifying and frustrating. response of health workers, the transformation of their attitudes, and the carryover of training into individual and national initiatives have all been positive. But the lack of funds and trainers, and the failure to recognize that breastfeeding requires national goals and positive management if it is not to atrophy, combine to make training difficult. Obstacles such as these can best be overcome by joint international efforts, applied both in developing and industrialized countries, to ensure every baby rich or poor has the same chance at being breastfed in the ideal pattern. References Ross SM, Loening WER, Mbele BE: Breast-feeding support. S Afr Med J 72: 357, 1988. Ladas A: How to help mothers breastfeed. Clin Pediatr 9: 702, 1970. Meara H: The key to breastfeeding in a non-supportive culture. J Nurse Midwifery 21: 20, 1976. Swaziland Breastfeeding Campaign Group: Survey of knowledge and attitudes of health workers in Swaziland with respect to breastfeeding. (duplicated) SBCG [now SINAN], Mbabane, 1986.
11
12 13 14
15 16
17 18
19 20 21 22
23
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Veldhuis M, Nyamwaya J, Kinyua M et al: Knowledge, Attitudes and Practices of Health Workers in Kenya with Respect to Breastfeeding, pp 60. Breastfeeding Information Group and UNICEF, Nairobi, 1982. Zimbabwe Ministry of Health and Zimbabwe Infant Nutrition Network: Survey of knowledge and attitudes of health workers in Zimbabwe. (duplicated) Ministry of Health, Harare, 1987. Rea M: Experience in Brazil has shown that breastfeeding retraining for 2-3 days may diminish health worker’s effectiveness in aiding mothers, whereas longer training enhances their skills. Personal communication, Dec. 8, 1988. Gatara TH: International Baby Food Action Network, Africa Region Programme Evaluation Report. (duplicated) IBFAN, Nairobi, 1988. King FS: Helping Mothers to Breastfeed. AMREF, Nairobi, 1985. IOCU/lBFAN: Protecting Infant Health, a Health Worker’s Guide to the International Code of Marketing of Breast-milk Substitutes, 3rd edn. IOCU/IBFAN, Penaning, 1987. Mothers and Children, Bulletin on infant .feeding and maternal nutrition. Three times yearly from American Public Health Association, 1015 15th Street, N.W., Washington, DC 20005, USA. Dialogue on Diarrhoea. From AHRTAG, 1 London Bridge St., London SE1 9SG, UK. Teaching Aids at Low Cost, P.O. Box 49, St. Albans, Herts. AL1 4AX, UK. Clearinghouse on Infant Feeding and Maternal Nutrition, at APHA, 1015 15th Street, N.W., Washington, DC 20005, USA. Werner D, Bower B: Helping Health Workers Learn. The Hesperian Foundation, Palo Alto, 1982. IBFAN Africa and UNICEF: Feeding Low Birth Weight Babies (videotape) from Radio/TV section DIPA, UNICEF, 3 UN Plaza, New York, NY 10017, USA. UNICEF: Facts for Life. UNICEF, New York, 1989. International Board of Lactation Consultant Examiners, Executive Secretary, 2315 Wickersham Circle, Germantown, Tenn. 38138, USA. Wellstart, P.O. Box 87549, San Diego, CA 92138, USA. Lawrence RA: Breastfeeding; a Guide for the Medical Profession, 3rd edn. CV Mosby, St. Louis, 1989. Neville MC, Neifert MR: Lactation; physiology, nutrition, and breast-feeding. Plenum Press, New York, 1983. Breastfeeding Abstracts. Quarterly from La Leche League International, P.O. Box 1209, Franklin Park, IL 60131, USA. Breastfeeding Briefs. From Geneva Infant Feeding Association. Box 157. 1211 Geneva 19. Switzerland.
Health care
practices
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1~. J. Gynecol. Obsret., 1990,31 (Suppl. 1): 91-103 International Federation of Gynecology and Obstetrics
Breastfeeding promotion: outreach health workers
training
of mid-level and
H.C. Armstrong Lactation and Training Consultant, IBFAN Africa, P.O. Box 34308, Nairobi (Kenya)
Abstract
The process
The International Baby Food Action Network Africa Regional Office (IBFAN Africa) has given thirteen courses in lactation management to subSaharan health workers. The aims of training, the process of running national courses in collaboration with local organizers, and the content of one- to twoweek courses are described. Available teaching resources include books, abstracts, films and slide sets. Forty topics are suggested for mid-level training, with a sample exercise teaching observation of a breastfeed. A twoweek course leads participants through four stages of attitude change. Obstacles to training are listed and solutions recommended.
Each course is given in collaboration with a local organizer, either a private voluntary organization or a ministry of health. The local organizer defines the need, secures government permission, identifies 25-45 participants, and secures local funding for all in-country expenses. The local organizer also arranges for a venue, accommodation, transport, and teaching facilities. IBFAN pays the cost of bringing in outside trainers if needed, books, visual aids, and any trainers-in-training (TRITs) from other countries. A timetable is worked out jointly between IBFAN and the organizer. TRITs are selected as having potential to run training courses in their own countries. They assist the training team, learning from the inside what is entailed and getting some supervised teaching practice. Typically they already have some knowledge of breastfeeding management which deepens as they attend all sessions, take responsibility for parts of the program, and do extra reading. Besides nurses and midwives, we train community health workers, nutritionists, and Breastfeeding support in lay counselors. Africa cannot be left only to the already overburdened workers in health care facilities. Lay counselors in South Africa [l] and in
Introduction Since 1985, the Africa Regional Office of the International Baby Food Action Network (IBFAN Africa) has trained midwives, nurses, and community health workers in lactation management. We have worked in 13 one- to two-week courses in Kenya, Uganda, Ethiopia, Zambia, Zimbabwe, Swaziland, Mauritius, Botswana, and Liberia, as well as in shorter workshops in Tanzania and Zanzibar. 0020-7292/X-J/$03 SO C%1990 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
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92
APPROXIMATE
COSTS IN U.S. DOLLARS - LACTATION MANAGEMENT COURSE
Jointly sponsored by MCH Coordinating Office, Government of Ethiopia and IBFAN Africa with local funding from UNICEF Ethiopia Programme, held in Nazret, Ethiopia September 18-29, 1988 (10 working days) IBFAN TRAVEL 1 preplanner, Kenya 2 resource persons, Germany and Kenya 1 TRIT, Zambia 45 participants, Ethiopia (including petrol) 2 drivers, per diems
HONORARIUM 1 resource person, Germany CONSULTING AND COORDINATING SERVICES Consulting Administrative and general costs
RESOURCES Books for participants, and handouts Books and visual aids given MCH offices of 13 regions
2140.00 251.21 2391.21
6169.21
150.00 2ooo.00 11413.00 362.32 2178.74 879.23 27.00 2177.00
14833.29
17010.29
800.00
800.00
2700.00 1538.25 4238.25
4238.25
500.00 300.00 800.00
800.00
STATIONERY AND SECRETARIAL HELP 1 secretary per diems Stationery for participants and secretarial use
MISCELLANEOUS TOTAL
TOTAL
298.00 2690.00 630.00
3778.00 FOOD, ACCOMMODATION 1 preplanner 2 resource persons and I TRIT 45 participants 2 Ethiopian resource persons 8 facilitators (5 attended all sessions) rent of meeting rooms and office childcare
UNICEF/MOH
11793.25
169.08 172.71 341.79
341.79
1207.73
1207.73
18714.02
30567.27
45 Ethiopian participants, 2 Ethiopian resource persons, 5 Ethiopian facilitators, 1 Zambian TRIT, 55 beneficiaries which work out to 5576.74 per person Fig. 1. Costs of typical in-country two-week courses.
the United States [2,3] have been shown to be very effective. In Zambia and Zimbabwe, we provide books and other training costs for community volunteers prepared by La Leche League to run mothers’ support groups. Only Int J Gynecol Obstet 31 (SupplI)
a few can benefit from such an intensive apprenticeship approach, but the training is of unparalleled thoroughness and relevance to the immediate needs of mothers. For most people, locally organized courses
Training of health workers APPROXIMATE
93
COSTS IN U.S. DOLLARS - LACTATION MANAGEMENT COURSE
Jointly sponsored by Breastfeeding Advocacy Group of Monrovia, Liberia and IBFAN Africa with local funding from UNICEF Liberia Program, held at Phebe Hospital, Bong County, Liberia September 14-25,1987 (10.5 working days) IBFAN TRAVEL 3 resource persons, Kenya and Uganda 2 TRITS, Ghana 1 participant, Sierra Leone 35 participants, Liberia
UNICEF/BAG
TOTAL
2845.00 2845.00
878.65 878.65
3723.65
FOOD, ACCOMMODATION 3 resource persons and 2 TRITS 1 participant, Sierra Leone 35 participants, Liberia
3270.00 655.00 3925.00
7320.00 7320.00
11245.00
HONORARIUM 1 resource person, Uganda
1250.00
1250.00
3200.00 1797.30 4997.30
4997.30
CONSULTING AND COORDINATING SERVICES Consulting Administrative and general costs
RESOURCES Books for participants, visual aids Overweight luggage payment for books Photocopying articles for participants
STATIONERY AND SECRETARIAL SERVICES
600.00 107.00
707.00
118.40 118.40
825.40
55.00
210.00
265.00
123.05
123.05
8650.10
22429.40
MISCELLANEOUS TOTALS
13779.30
35 Liberian participants, 1 Sierra Leone participant, 2 Ghanaian TRITS, 38 beneficiaries which works out to $596.25 per person. Fig. 1. (Continued).
are the most feasible training method. We feel that unless people from the country itself play an active role in organizing and following up on a course, its impact is likely to be minimal. Advantages of training nationals in their own country National courses can be adapted to the country’s needs and conditions. Discussions of nutrition and family planning, epi-
demiological studies, and national policies are possible when all participants come from a single country. The realism of a national course cannot be matched by one elsewhere, which may take place in circumstances not resembling those at home. Small group discussions, role plays, and hospital field work carried out in African languages promote enthusiastic full participation. We have noted that counseling skills learned in one language do not necessarily get applied in another; hence counseling practice Health carepractices related to breastfeeding
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in the actual language of daily work is most beneficial. The training team consists of nationals and outside trainers. Resource people selected from among the country’s medical and nutri-
tion specialists have chances to meet trainers, pick up information as they sit in on other sessions, and become sensitized to the recent significant changes in lactation knowledge. Importing resource people is dramatically
The aim of this form is to help you to learn how to observe a breastfeed. It does not diagnose every breastfeeding difficulty, but helps to select mothers who need more careful attention. Items in brackets apply only to the newborn, not to the older baby. If wished, a score of ten may be arrived at by scoring sections B, R, E, A, and S with 2, 1, or 0, in a manner similar to Apgar scoring. Lines are provided for tick marks next to specific items. If all ticks are in the left hand column, score 2 for that section. If all are in the right hand column, score 0. If they are scattered, use your judgment. If in doubt, give a lower score. The time spent in actual breastfeeding is an important observation, especially if the mother tends to terminate every feed in less than three or four minutes. Babies given very abbreviated feeds may lack the fat-rich hind milk, and get more lactose-containing fore milk than they can easily digest. Some mothers also will terminate feeds before their milk ejection reflex has got well started. Provide followup, including history taking and suck assessment, to any baby and mother who score rather low on this observation, or if the baby is not gaining weight adequately. BODY POSITION - trunk-to-trunk - baby facing breast - head and body aligned [arm position?] - chin on breast - Ibottom supported]
-
body distant from mother’s drooping or off to one side curled or twisted chin away from breast - [only shoulders or head supported]
RESPONSES -
Irooting reflex1 [homing-in responses1 reaches for breast when hungry calm and alert at breast signs of milk ejection reflex in mother
EMOTIONAL BONDING - en face attention from mother - much touching
- [no rooting] - [no homing-in] - no response to breast when hungry - restless or fussy at breast, slips off - no signs of ejection reflex
- no eye contact - minimal touch - nervous, shaking, or limp hold
- secure hold ANATOMY
- breast engorged - nipples flattened, inverted - nipple pain or fissures
- breasts soft - nipples protractile - no nipple pain or fissure SUCKLING - mouth wide open - rhythmic burst-pause sucking/swallowing - tongue visible, cupped - cheeks plump TIME spent actually suckling _ Fig. 2.
Observation of breastfeeds.
Int JGynecol Obstet 31 (Suppl I)
minutes
-
mouth pursed or lax fluttering or clicking sucking tongue not visible cheeks tense or drawn in
Total score.._/I0
Training of health workers
cheaper than sending even a handful of trainees out of their country. Our two-week Liberian and Ethiopian courses worked out at under US$600 per participant, including all local and IBFAN expenditures (Fig. 1). Although in any course there will be a few who did not take much in, a larger number of informed and energized people can be generated by in-country training than by selecting a few to send out. And among the number, there will almost certainly be some who go on actively to apply what they have learned. Mid-level training Many health workers lack up-to-date information on lactation, the ability to diagnose and resolve breastfeeding problems, and the counseling skills which would empower the mother to breastfeed successfully [4--61, In all countries, we have found early signals of breastfeeding failure ignored by health staff, although later they must deal with the major difficulties eventuating from untreated earlier problems. But African health workers do not have time for one-to-one counseling of every mother. We teach trainees to spot the particular women who definitely need focused help, using clues such as observation of a breastfeed (Fig. 2) or growth faltering before 4 months. In addition, since health workers have been trained primarily in a negative approach - to look for problems, to criticize and correct, and to tell women what to do - they may need to learn how to recognize and reinforce good health practices. For instance, few health workers customarily encourage a mother who is breastfeeding a one-year-old to continue for another year. They are more likely to wait for the toddler to develop weanling diarrhea or malnutrition, and then demand of the mother “Why aren’t you breastfeeding?” IBFAN courses aim to overcome some deficits among mid-level health workers: - unquestioning acceptance of customs, whether traditional or medical;
95
-
negative attitudes due to their own past breastfeeding history; a lecturing rather than supportive approach to mothers; out-of-date information on lactation management; - lack of understanding about the formation of national policies, including Codes of Marketing of Breast-milk Substitutes and about proceses of change; and - lack of practical experience in preventing, diagnosing, and overcoming breastfeeding problems. In 1986, IBFAN Africa held a meeting of trainers from seven countries specifically to develop ideas on the content of mid-level health worker training. Their suggestions were written up into a training outline which has been field tested during 1987 and 1988. A final outline giving lesson plans for forty topics (Fig. 3) is now being developed. The whole list is clearly impossible to cover in one short course. Organizers are asked to analyze the needs of their participants, and to select the most relevant topics. They also add topics in accord with national priorities. Yet regardless of how careful the timetabling, participants end every course by saying, “We needed more time. Please add another week.” Stages of change during a course One obstacle to be overcome in each country is the reluctance of administrators to release health workers for even two weeks’ training. Often they ask us just to give a oneto two-day “awareness” workshop, believing that health workers only need greater motivation to promote breastfeeding. We encourage them to compare our modest request with the length of time usually given to family planning courses: four to six weeks. To learn modern breastfeeding management and unlearn established patterns is at least as complex. A single day or two cannot counter years of internalized misinformation and a habitual recourse to bottles. Health workers’ natural resistance to Health care
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INFANT FEEDING IN THE NATIONAL CONTEXT 1. Why is braastfaeding integral to child survival strategies? 2. Traditional patterns and current national trends in infant feeding 3. National food and health issues 4. National policies affecting infant feeding 5. Commercial practices in the country
LACTATION MANAGEMENT 6. Anatomy and physiology 7. Biochemistry and immunology 8. Antenatal preparation and giving birth 9. The first breastfeeds 10. Nipple pain and positioning 11. Breast problems and expression techniques 12. Not enough milk and relactation 13. Sick and low birth weight babies 14. Special situations 15. The working mother 16. Maternal nutrition during lactation 17. Sucking problems and refusing the breast 18. The ideal breastfeeding duration: value of breastmilk during the second year 19. Growth of the baby and young child 20. Foods and feeding during the weaning interval 21. Breastfeeding and child spacing 22. Drugs and breastfeeding 23. Breastfeeding management during illness in mother or baby
COUNSELLING (working with an individual mother) 24. Observation of brestfeeding 25. Psychological factors in breastfeeding 26. Listening and learning from mothers - facts and feelings 27. Taking a history; making a diagnosis 28. Acceptance and support; building a mother’s confidence 29. Running a mother support group
HEALTH EDUCATION (working with groups and communities) 30. Communication skills 31. Choosing who needs to know what: targets and messages 32. Leading group education: alternatives to the lecture method 33. Reeducating health workers and policy makers 34. Using mass media 35. The stages of change in ourselves and colleagues 36. Resources for continuing self-education
ACTION FOR NATIONAL POLICIES TO PROMOTE BREASTFEEDING 37. What is the International Code of Marketing? 38. Implementing the Code and closing loopholes 39. Code monitoring and health worker’s responsibilities 40. Recommendations for a national plan
Fig. 3.
IBFAN
Africa
topics
Int J Gynecol Obstet 31 (Suppi I)
for mid-level
health
worker
training.
Training of health workers
change should not be underestimated. Someone who has run a nursery for 15 years, bottle feeding every baby “until the mother’s milk comes in”, cannot immediately jettison her belief in the need for this routine. Immediate skin-to-skin breastfeeding contact and postpartum comes as a shocking new idea to midwives trained to wrap the newborn right away, separate it from the mother so both can “rest”, and give it a complete bath before it is taken to the mother hours later. It takes time for the possibility of different management to become acceptable. There is another ingredient in resistance. Personal breastfeeding experiences, many of them negative, must be recognized so that retraining can start. Most health workers now practicing did not themselves give four to six months of exclusive breastfeeding, or nurse through their child’s second year. In particular, those who are now old enough to be in leadership positions were in a generation which was influenced in the direction of artificial feeds by the absence of any information save that generated by commercial interests. These parents have an emotional stake in believing that their children did not suffer in any way from bottle feeding. They need to be reassured that they are good parents, that like all of us they did the best they could according to what they knew at the time. Only then are they ready to start accepting new ideas, looking for what might have gone wrong in their own case, and forgiving themselves for any mistakes. They become ready to analyze what influenced them, and prepared to help others avoid the same pitfalls. If they are not given time for this change, they will simply hold to their belief, based on disappointing personal experience, that breastfeeding while ideal in theory just doesn’t work out in practice. There are recognizable stages in the process of change during a course: (1) Ennui. People wonder why the course is needed. Breastfeeding after all is natural, much preached about. widely practiced,
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There really is no problem, so why bother with a course? (A one-day workshop rarely gets beyond this stage). (2) Resistance. If enough new information is discussed during the first two days, by the second or third day there should be some kind of resistance, as participants see the challenge to their established routines. Argument, denial, and some anger may be expected, expressed in culturally appropriate ways. Participants will also start listing problems, without solutions, and assigning blame: “The mothers are careless.. .The doctors expect us to use formula....The government doesn’t give enough maternity leave.. , .We have too many patients. . ..A11 our patients breastfeed in the hospital so it must be the fault of the maternal and child health (MCH) clinics...“. (A two or three day workshop will end at this inopportune moment, just when negativism and confusion have become strongest [7].) (3) Absorption. From the fourth day onwards, the atmosphere tends to change. Participants begin to warm up to the topic and to each other. They talk more freely of their own experiences, both personal and clinical, they look for solutions to problems, they read with more energy, and discuss breastfeeding topics in free time. Field trips at this time are rewarding, as participants talk at length with mothers and notice aspects of breastfeeding previously unremarked. (4) Looking forward. Towards the end of the course, participants focus on needed changes: how they might persuade colleagues; what health education materials they need; what national initiatives are required and how they might be brought about. It is helpful to discuss processes of change so participants will not expect radical conversions overnight. Constructive and cooperative planning of action without the element of blame is possible at this stage. A strong argument for courses of at least two weeks is that transforming one’s attitudes - towards mothers, breastfeeding, oneself,
Health care practices related to breastfeeding
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Armstrong
and change itself - is difficult and can be painful. It cannot effectively be compressed into a couple of days. Outcome and evaluation Our courses are part of a whole process of networking, helping groups to form and encouraging them to analyze local needs, to develop programs of counseling, Code advocacy, or publications, to undertake informal surveys, and to seek funding. We prefer not to run a course where there is as yet no group to do advance work and follow-up. Thus it is hard to assess the impact of an IBFAN course in isolation. However we are convinced that training is the basis for changes which will be sustained, and that it stimulates further serious attention to breastfeeding in any country. We get positive feedback from every course, and most participants show marked improvement on a post-test compared to a pre-test. Though we have no systematic evaluation thereafter, continuing correspondence with organizing groups indicates diverse outcomes: transformation of a maternity unit in Zambia; vernacular radio programs in Liberia; formation of a vigorous national Code committee in Ghana; development of community counseling services in Mauritius; elimination of bottles from government hospitals in Kenya. We cannot say that one course was the sole factor in a change - it may have been a catalyst or one ingredient in a complex reaction. A 1988 evaluation of the entire IBFAN Africa program, which includes other activities as well as training, concluded: The networks view IBFAN’s training programs as successful, impressive, and participatory. In their view the course structure is comprehensive....A lot of good planning goes into the program....The networks further express the view that training people to train others is IBFAN’s most outstanding effort [8].
Local organizing groups and funding donors both seem convinced that our courses have been worth the effort and the money.
Int J Gynecol Obstet 31 (Suppl I)
Resources Many training workshops provide no books; instead they give diverse handouts including mimeographed notes of sessions. We find that these simply gather dust afterwards, having no indexes, bindings or any particular order. We therefore provide textbooks for every participant to study, to show colleagues later, and to refer back to. For mid-level health workers we use F. Savage King’s Helping Mothers to Breastfeed [9] and IBFAN’s Protecting Infant Health [lo]. A library of additional reference books is available throughout the course, and is left with the local organizing group to fuel further self-education. Duplicated handouts are distributed with supplemental national information, such as health, nutrition, and cultural studies. Additional helpful materials have been the newsletters Mothers and Children [ 1l] and Dialogue on Diarrhoea [ 121 and the visual aids produced by Teaching Aids at Low Cost [ 131. We give out selected photocopied articles provided from our files and also from the Clearinghouse on Infant Feeding and Maternal Nutrition [ 141. The methodology resource Helping Health Workers Learn [ 151 is invaluable, as are slides and films by United Nations Children’s Fund (UNICEF), including our joint videotape Feeding Low Birth Weight Babies [ 161. Caution is needed with visual aids. Quite apart from the likely absence of electricity, room-darkening curtains, and a projector, sessions based primarily on prepared transparencies and slides are not vivid enough. It works better to use a blackboard or flip chart to write down key words and phrases as discussion proceeds. Course participants thrive on eye contact, on give-and-take, and on realistic presentations including brief role plays, demonstrations, and pair practice. Charts and graphs can be helpful to illustrate specific points, but participants may lack experience in drawing practical management
Training of health workers
conclusions froin a mass of data. Slides are a useful adjunct to, but not a substitute for, work with real mothers through clinic visits. Obstacles to training programs “There is no problem” thinking Immersed in more dramatic problems, both national and international officials can easily assume that breastfeeding is one thing they do not have to worry about, particularly if they mistake breastfeeding starts (the “ever breastfed” figure) for a degree of breastfeeding which ensures better health. They may be unfamiliar with the health, nutrition, and child spacing implications of breastfeeding declines. Recommendation: Persuade policymakers that breastfeeding requires attention by demonstrating the relevance of studies done elsewhere. Avoid if possible the delays and expense of tediously replicating basic work in every country. Acceptance of breastfeeding failures Lactation management now tends to be ignored as was the field of obstetrics two hundred years ago, when childbirth was seen as of no particular scientific interest, and a certain wastage of mothers and children was regarded as inevitable. Medical schools still training in the give no specialized multidisciplinary field of breastfeeding. Policymakers may still accept the infant wastage resulting from minimal or no breastfeeding by millions of women, because they have not realized that breastfeeding failures are in large part preventable and may be iatrogenic. Recommendation: Recognize that breastfeeding failures indicate a need for urgent policy action, and that better breastfeeding practices will pay off in better health, nutrition, and child spacing. Commercial influences on policymakers Manufacturers continue to transmit information to policymakers indicating that many women cannot breastfeed, and bottles of
99
commercial formula are the only alternative. The manufacturers’ list of situations in which formula will be required includes an enorill, teenage, range: employed, mous undernourished, overworked, and reluctant women; and premature, sick, handicapped, hospitalized, very big, very small, and slowgrowing babies and even, ironically enough, babies possibly allergic to cow’s milk, and babies suffering from diarrhea caused by bottle feeding. These categories usually take in most of the families in any country. Even health workers have allowed choices to become narrowed down to a simple dichotomy, the breast or the bottle of formula. Those unversed in lactation management accept such persuasive “professional information”, which subtly provokes many doubts about breastfeeding, as a basis for public policy decisions. Too often, the most readily available money for breastfeeding research and for conferences on lactation also comes from sources whose primary interest in breastfeeding is as a brief prelude or an accompaniment to feeding with commercial products. Objective scientific information is not reaching key people. Recommendation: Information provided to health professionals or to policymakers from commercial sources should be, in accord with the International Code of Marketing of Breast-milk Substitutes, strictly scientific and factual. Public funding is needed to ensure that professionals can undertake and report research free of distorting factors. Restraints on other forms of commercial influence upon health policymakers should be considered at the national level. Confusion of description with action Numerous countries limit their breastfeeding program to studies of what is happening, and follow with no intervention. Sometimes the studies are repeated at five or ten year intervals, with no protection, promotion, or support during the interval. Recommendation: Specific action programs
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should ensue from any study which documents a decline in breastfeeding. Confusion of custom with what is best Traditional breastfeeding practices may not be ideal for health. Colostrum is widely denied to newborns, and watery additional fluids have acquired the force of custom in many communities. An abrupt cessation of breastfeeding may be counseled following any 24-hour interruption in breastfeeding, a return to sexual relations, or as soon as a new pregnancy is suspected. Such deeply embedded customs may be valuable or may be detrimental to breastfeeding; analysis is needed. Custom cannot be allowed to justify perpetuation of truly harmful practices. Recommendation: Avoid simplistic romanticism about infant feeding traditions, and aim to change those not in the best interest of babies. The myth of integration Integration of breastfeeding into all child survival strategies is an excellent theory, yet so far has tended to make breastfeeding virtually invisible and unfunded. Many programs incorporate a “breastfeeding component”, which scrutiny may reveal is limited to simple exhortations to breastfeed, a limited-distribution pamphlet, or a poster. In too many programs, emphasis, funds, training, and supervision are concentrated upon Expanded Programs on Immunization (EPI), oral rehydration therapy (ORT), family plan- ’ ning, growth monitoring, and programs which stress soft foods whilst failing to encourage continued substantial breastfeeding. A look at any nation’s expenditure on family planning and on breastfeeding respectively is usually illuminating, as is a look at the time use of health workers in “integrated” programs. Breastfeeding support may be overlooked at the clinic level, at the district planning level, and in national budgeting. Ideally lactation goes on much longer than a pregnancy. However, it is far more subject Int J Gynecoi Obstet 31 (Suppl I)
to disruption by cultural beliefs and by mismanagement. Bad advice, worry, and doubt do not cross the placenta, but cause thousands of breastfeeding failures. Integration of breastfeeding into health worker training has so far, however, reflected traditional disproportion: weeks spent on pregnancy, perhaps half a day spent on lactation. Recommendation: First provide specialized training in breastfeeding, to counteract past omissions. Then integrate breastfeeding into all programs and training activities, giving it emphasis, time, and funding consonant with its complexity and its central importance to child survival. The myth that any doctor can talk about breastfeeding A few of the resource persons who are chosen by local organizers to address our courses exemplify the the failure to recognize lactation as a specialist field, by giving lectures based on outdated or very approximate knowledge. On occasion, an obstetrician who has seldom looked above the fundus or beyond the six week checkup is brought in to speak about the whole course of breastfeeding. Non-specialist doctors have also been used by both national and international agencies to write or approve breastfeeding publications and programs, with embarrassing inadequacies in consequence. Recommendation: Recognize lactation management as a specialized field where both recent knowledge and clinical experience are necessary qualifications for teaching or writing. Confusion of institutional changes with ongoing support Even for the minority of African babies born in hospitals or health centers, contacts with any health facility are few, perhaps 12 days in two years of breastfeeding. A woman worried about her baby during the other 718 days of lactation will turn to relatives and friends, or the village health agent. The
Training of health workers
general level of knowledge in her support network must be good. Focusing exclusively on changing practices in health institutions may not alter dangerous community-based patterns of early addition of non-breast milk drinks and foods or abbreviation of breastfeeding. Recommendation: Ensure through public health education that ongoing support at the community level is part of every breastfeeding promotion campaign. Absence of explicit recommendations Neither health workers nor mothers are as yet receiving clear guidance from their health authorities on just how much and how long to breastfeed. Neither training nor other breastfeeding promotion strategies can be effective without explicit recommendations. This is especially important where, as in many African countries, mothers are lessening the intensity and abbreviating the duration of breastfeeding. The vague phrases “as much as possible”, or “as long as you can” leave health workers and parents with the sense that neither exclusiveness nor duration are of much significance. In contrast, other feeding messages are very specific - five meals a day at 18 months, 1100 kcal per day, 20 g of protein, and the like. Nations and agencies should not hold back from establishing clear breastfeeding goals because not all women can or will follow them. Such a reservation could apply to all feeding recommendations. We urge so many meals per day, so much protein and energy food, knowing very well that some children will not get them. It is our responsibility to define what is best for the child, and then see what programs we can implement to ensure that those needs are met, for the children of every nation. UNICEF has taken an international lead by stipulating a pattern: exclusive breastfeeding for four to six months [17]. Parents also need to know how long to go on breastfeeding, with the understanding that breastfeeding can well be continued longer but should
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not be stopped earlier than the target age, perhaps 18 months or 2 years. Recommendation: National and international agencies should set targets for the guidance of mothers and health workers, stipulating the ideal length of exclusive breastfeeding, and the recommended minimum duration. Lack of funding Because breast milk does not appear in most economic reckonings, its value has usually been overlooked. Although the monetary value of breastfeeding is now being proven by the costs of its erosion, most countries as yet provide no funds for its preservation. Without money for training, publications, research, social marketing, office costs, transport, and, even more importantly, without full time salaries for breastfeeding specialists, breastfeeding will not flourish. Yet we can name only one civil servant in the whole subSaharan continent, and less than ten counselors working with non-governmental organizations, who at present receive full time salaries for breastfeeding promotion. This is not to say that only salaried professionals are qualified to give breastfeeding help; it has always been and should remain part of ordinary women’s special province. Nevertheless, we need professionals to reinforce mothers’ experience with research, publications, training, and sound medical advice. Recommendation: Establish salaried full time positions with adequate program budgets for lactation specialists. Shortage of trainers Related to the absence of salaries and of specialized advanced courses is a dearth of qualified trainers. Those used by IBFAN and most national programs are earning their living from some other role, and can spare little time for breastfeeding work. Yet good trainers are rare. They need three qualifications: sound lactation knowledge, wide clinical experience with mothers, and a flexible nonHealth care practices related to breastfeeding
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authoritarian teaching style. At present, the world’s specialists in lactation are largely selfeducated in the field. But in Africa, self-education by health professionals is greatly inhibited by very heavy clinical responsibilities, and by inaccessibility of journals and books. A recently developed examination, set annually by the International Board of Lactation Consultant Examiners [18] tests some aspects of breastfeeding knowledge and may be helpful in identifying competent trainers. However, it does not measure skills in working directly with mothers, nor in teaching. Our TRIT program attempts to prepare Africans to take on more substantial training roles, but is far too cursory to make expert trainers out of people to whom the field is relatively new. We encourage subsaharan countries to send teams to the San Diego Wellstart program, a groundbreaking effort giving both international experience and a month’s concentrated learning to senior medical workers [19]. However, even this pioneering program is too brief; six months or more would be preferable. Recommendation: The effect of courses is minimized when graduates are poorly deployed and absorbed into general medical functions, as has happened with some African Wellstart graduates. A national commitment and budgetary provision to employ the participant afterwards in training others should accompany enrollment in a lactation specialist course. Lack of resources in non-English languages Although we now have some good training materials in English, there is little in other international languages. We do not have in French or Spanish professional-level referenced medical textbooks equivalent to those in English by Lawrence [20] and by Neville and Neifert [21]. Simple, non-referenced publications, such as Helping Mothers to Breastfeed, Protecting Infant Health, and Mothers and Children are fortunately available or forthcoming in Spanish, French, and Int J Gynecol Obstet 31 (Suppl I)
sometimes other international languages. But trainers need more substantial reference works. Slide sets, videotapes, and films also require translation. So far, the rapid expansion of knowledge about breastfeeding management has bypassed far too many language communities. Recommendation: Urgent action is needed to provide substantial professional resources for trainers in French, Spanish, Arabic, and Portuguese, including abstracts similar to Breastfeeding Abstracts [22] and Breastfeeding Briefs [23]. The World Health Organization (WHO) has a role to play in ensuring that its technical documents on infant feeding are published in all United Nations languages. Getting the right people into training Too often the participants invited by the organizers are not released, while others of questionable suitability are sent to replace them. Inappropriate participants are a pervasive problem of all health training, not only of breastfeeding courses, and they alter the atmosphere and effect of any course. Recommendation: Emphasize selection of key people, and give incentives if necessary to encourage their attendance. In a single village clinic, one can usually find some mothers with malnourished children, and other mothers from the same milieu with very healthy children. We have not yet made adequate use of the successful village mothers, training them to reassure and advise their neighbors. Yet the best counselor for a breastfeeding mother with ordinary perplexities is likely to be her peer who is near at hand. Recommendation: Do more to provide training and recognition of lay breastfeeding cormselors at the village level. Providing enough practice with real mothers Only an apprenticeship training gives adequate experience with mothers under favorable conditions. With a group of 25 or more in a course, the trainers have difficulty getting round to see each participant with a mother
Training of health workers
even once during a hospital field trip. Language difficulties may frustrate communication, especially where participants in a nationwide course do not share the vernacular used locally. Mothers can also feel overwhelmed and intimidated by a large number of trainees craning to see how their babies suck. Recommendation: Once salaried breastfeeding specialists are available at the country level, they should provide follow-up to courses by giving participants one-to-one clinical training with mothers .
5
6
7
8
9
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IBFAN Africa’s experience with training of mid-level health workers has been both The ready gratifying and frustrating. response of health workers, the transformation of their attitudes, and the carryover of training into individual and national initiatives have all been positive. But the lack of funds and trainers, and the failure to recognize that breastfeeding requires national goals and positive management if it is not to atrophy, combine to make training difficult. Obstacles such as these can best be overcome by joint international efforts, applied both in developing and industrialized countries, to ensure every baby rich or poor has the same chance at being breastfed in the ideal pattern. References Ross SM, Loening WER, Mbele BE: Breast-feeding support. S Afr Med J 72: 357, 1988. Ladas A: How to help mothers breastfeed. Clin Pediatr 9: 702, 1970. Meara H: The key to breastfeeding in a non-supportive culture. J Nurse Midwifery 21: 20, 1976. Swaziland Breastfeeding Campaign Group: Survey of knowledge and attitudes of health workers in Swaziland with respect to breastfeeding. (duplicated) SBCG [now SINAN], Mbabane, 1986.
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19 20 21 22
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Veldhuis M, Nyamwaya J, Kinyua M et al: Knowledge, Attitudes and Practices of Health Workers in Kenya with Respect to Breastfeeding, pp 60. Breastfeeding Information Group and UNICEF, Nairobi, 1982. Zimbabwe Ministry of Health and Zimbabwe Infant Nutrition Network: Survey of knowledge and attitudes of health workers in Zimbabwe. (duplicated) Ministry of Health, Harare, 1987. Rea M: Experience in Brazil has shown that breastfeeding retraining for 2-3 days may diminish health worker’s effectiveness in aiding mothers, whereas longer training enhances their skills. Personal communication, Dec. 8, 1988. Gatara TH: International Baby Food Action Network, Africa Region Programme Evaluation Report. (duplicated) IBFAN, Nairobi, 1988. King FS: Helping Mothers to Breastfeed. AMREF, Nairobi, 1985. IOCU/lBFAN: Protecting Infant Health, a Health Worker’s Guide to the International Code of Marketing of Breast-milk Substitutes, 3rd edn. IOCU/IBFAN, Penaning, 1987. Mothers and Children, Bulletin on infant .feeding and maternal nutrition. Three times yearly from American Public Health Association, 1015 15th Street, N.W., Washington, DC 20005, USA. Dialogue on Diarrhoea. From AHRTAG, 1 London Bridge St., London SE1 9SG, UK. Teaching Aids at Low Cost, P.O. Box 49, St. Albans, Herts. AL1 4AX, UK. Clearinghouse on Infant Feeding and Maternal Nutrition, at APHA, 1015 15th Street, N.W., Washington, DC 20005, USA. Werner D, Bower B: Helping Health Workers Learn. The Hesperian Foundation, Palo Alto, 1982. IBFAN Africa and UNICEF: Feeding Low Birth Weight Babies (videotape) from Radio/TV section DIPA, UNICEF, 3 UN Plaza, New York, NY 10017, USA. UNICEF: Facts for Life. UNICEF, New York, 1989. International Board of Lactation Consultant Examiners, Executive Secretary, 2315 Wickersham Circle, Germantown, Tenn. 38138, USA. Wellstart, P.O. Box 87549, San Diego, CA 92138, USA. Lawrence RA: Breastfeeding; a Guide for the Medical Profession, 3rd edn. CV Mosby, St. Louis, 1989. Neville MC, Neifert MR: Lactation; physiology, nutrition, and breast-feeding. Plenum Press, New York, 1983. Breastfeeding Abstracts. Quarterly from La Leche League International, P.O. Box 1209, Franklin Park, IL 60131, USA. Breastfeeding Briefs. From Geneva Infant Feeding Association. Box 157. 1211 Geneva 19. Switzerland.
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practices
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