Health professionals’ and stakeholders’ perspectives on the uptake and implementation of the Baby Friendly Hospital/Health Initiative (BFHI) in Australia

Anahita Esbati

doi:10.25907/00469

Extensive evidence supports the health and economic benefits of breastfeeding (Rollins et al., 2016), yet rates in Australia remain sub-optimal. The Baby Friendly Hospital/Health Initiative (BFHI) is an initiative of the World Health Organization (WHO) and the United Nations International Children’s Emergency Fund (UNICEF) to improve breastfeeding practices and to promote, support and maintain breastfeeding (World Health Organization [WHO], 1998). The BFHI has two parts: 1) the Ten Steps to Successful Breastfeeding (the Ten Steps), which highlights practices that support the initiation and maintenance of breastfeeding; and 2) the WHO International Code of Marketing of Breast-milk Substitutes (the WHO Code), which sets the standard expected of health facilities in relation to the promotion of breastmilk substitutes (WHO, 1998). The BFHI is known to be one of the most effective health service strategies capable of increasing breastfeeding rates and duration. In 1993, the Baby Friendly Hospital Initiative was launched in Australia. Currently, there are 70 Baby Friendly accredited facilities in Australia (Australian College of Midwives [ACM], 2018b), representing just 22% of facilities providing maternity services (International Baby Food Action Network [IBFAN], 2018). Considering Australia’s low implementation of the BFHI, the aim of this case study research was to explore health professionals’ and stakeholders’ perspectives about the uptake and implementation of the BFHI in Australia, through the application of an organisational change theory (Burke-Litwin, 1992). An exploratory sequential method, three-stage approach was employed, with the following research objectives: Stage 1 – the extent to which current legislation, health policies and guidelines supported breastfeeding and the BFHI in Australia at national, state and professional organisational levels (qualitative document analysis); Stage 2 – health professionals’ perspectives about the uptake and implementation of the BFHI in Australia (semi-structured interviews); and Stage 3 – health professionals’ and stakeholders’ knowledge and experience about the uptake and implementation of the BFHI in Australia (online survey). The integrated findings of the three stages of this research identified that the uptake and implementation of the BFHI is complex and that both macro and micro levels of organisational change are influential factors. This research concludes that there is a need for improvement in the external environment, including public and media support of breastfeeding, normalisation of breastfeeding and restricting the advertisement of toddler formula. Another key finding was the lack of legislative support for the BFHI and the WHO Code even though public health policies and guidelines are supportive of breastfeeding and the BFHI. Legislative and regulatory reviews and interventions are therefore needed to ensure the implementation of the BFHI and the WHO Code and enforce compliance and maintenance. Consideration of the health departments to increase resources, to prioritise and perhaps incentivise the uptake and implementation of the BFHI for health services would likely improve rates within Australia. In addition, improving breastfeeding and BFHI knowledge among staff, mothers, family members and wider society; effective interdisciplinary cooperation; communication and interaction skills among staff and between staff and mothers; continuity of care; and regular supervision and monitoring to ensure maintenance are required to achieve successful uptake and implementation. The use of Burke-Litwin model (1992) to analyse integrated findings also identified that a range of stakeholders, including leaders, management, staff, mothers, their family members and wider society play influential roles at both macro and micro levels of organisational change. Their support of breastfeeding and the BFHI was identified as positive and has potential to support organisational change. However, a lack of such support was perceived as a significant barrier to achieving successful uptake and implementation of the BFHI. This research is significant in that it is the first Australian study to apply a framework underpinned by organisational change theory (the Burke-Litwin model (1992)) to understand the limited uptake of the BFHI in Australia, from the perspective of key stakeholders and health care professionals involved. The document analysis conducted in Stage 1 of the research was also the first comprehensive qualitative analysis of all publicly available breastfeeding and BFHI-related documents. Drawing on these findings, it was concluded that to improve uptake and implementation of the BFHI as a complex initiative, engagement of supportive leadership, as well as improvement in policy and practice approaches at the macro and micro levels of change are required in Australia. However, further exploration is required as there are still gaps concerning several areas relevant to the macro and micro levels of organisational change. Such further research could provide suggestions on how to improve the uptake and implementation of the BFHI, which will likely improve breastfeeding initiation and duration throughout Australia.

Health professionals’ and stakeholders’ perspectives on the uptake and implementation of the Baby Friendly Hospital/Health Initiative (BFHI) in Australia

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