The World Alliance for Breastfeeding Action (WABA) is a global network of individuals
& organisations concerned with the protection, promotion & support of breastfeeding worldwide.
WABA action is based on the Innocenti Declaration, the Ten Links for Nurturing the Future and the
Global Strategy for Infant & Young Child Feeding. WABA is in consultative status with UNICEF & an NGO
in Special Consultative Status with the Economic and Social Council of the United Nations (ECOSOC).
WABA Activity Sheet 8

Training Health Workers in Breastfeeding Management

Why do health workers need to be trained?

Health workers have a great influence on infant feeding practices.
During their training, they may learn that breast is best, but seldom do they learn exactly what role breastfeeding plays in the good health of the families in their care. A growing body of research
over the last 15 to 20 years has demonstrated beyond any doubt that breastfed babies are healthier than their artificially-fed counterparts - and not only in the developing world. Exclusive breastfeeding for about six months is every baby's best protection against respiratory and digestive tract diseases. Continuing breastfeeding after supplementary  foods have begun, continues the protection. For many diseases there is long-term protection even after breastfeeding has stopped.

Even when health workers know this and are very much in favour of
breastfeeding, they may not know how to promote it, how to help mothers initiate and maintain breastfeeding or how to change policies that interfere with it. Female health workers in many countries may not have breastfed their own children and can feel too guilty, too defensive  or too confused to help other women breastfeed. And almost all health workers in every country feel the influence of the infant formula industry through its well-financed promotional and continuing education programmes.

Because the role of health workers in getting breastfeeding off to a good start and maintaining it can be decisive, it is critically important that training programmes address both their attitudes and their skills. Breastfeeding management and counselling should be integrated into the basic education of all health care professions and all health workers caring for mothers and infants should have frequent opportunities to update their breastfeeding information and skills.

The outreach and minimum knowledge of health workers. In a joint statement, Protecting, Promoting And Supporting Breastfeeding:
The Special Role Of Maternity Services, WHO and UNICEF in 1989 explicitly outlined how health workers can be prepared to promote and support breastfeeding. The health worker has in addition to her institution,a broad social stage to act upon and can influence breastfeeding policies and programmes.

The Baby Friendly Hospital Initiative (BFHI) is the result of the
WHO/UNICEF statement and is based upon the Ten Steps to Successful Breastfeeding. Health workers should understand the importance of the breastfeeding management strategies incorporated in the Ten Steps, including:

- initiating breastfeeding with- in a half-hour of birth;
- breastfeeding on demand;
- rooming-in - 24 hours a day;
- no supplementary food or drink other than breastmilk, unless medically indicated;
- no bottles, artificial teats or pacifiers for breastfeeding infants.

The International Code of Marketing of Breastmilk Substitutes considers health workers as a prime factor in the success or failure of the Code. They are the channel through which companies promote their products and so have a direct influence over mothers. The health worker equipped  with knowledge about the hazards that bottlefeeding can bring, has a key role to play in implementing the Code to cut short this channel.

Healthworkers should be motivated and convinced that:

- breastmilk is the best milk for babies;
- there is no real alternative to breastmilk;
- they are key people in the success or failure of lactation;
- promoting breastfeeding contributes to the long-term health and economic interests of a society;
- their efforts to promote breastfeeding are worth-while and should be commended.

Breastfeeding management

Because of their extreme importance to milk supply and prophylaxis
against breast problems, correct attachment and positioning should
be clearly recognisable to every health worker and each one should
be competent to teach mothers how to get their babies onto the breast correctly and comfortably. Managing breast-feeding problems from inverted nipples to feeding a low birth weight baby are also part of the health worker's skills.

Support for lactation requires coordination of services and team effort. Every mother should:

- be prepared for breast- feeding antenatally;
- be helped to start breastfeeding in the labour ward;
- be given adequate patient support and information on the postnatal ward;
- be followed up for at least 2 months after discharge;
- have additional support if her baby is sick or small;
- work to end free supplies of infant formula in your hospital.

Communication between the health worker and the mother

Although knowledge can be acquired in a classroom and through practical training, assisting a mother towards successful breastfeeding is a hands-on skill which requires sensitive listening and supportive counselling. These skills are not routinely included in the training curricula for most health care professions and should be added to their programmes.

In-house orientation and continuing education programmes too need
to place more emphasis on good communication between staff and patients and among the staff members if environments are going to be created which encourage mother-child bonding and nurture their breastfeeding relationship.

What can you do about health worker training?

- Provide your institution with copies of the Ten Steps to Successful Breastfeeding and the WHO/UNICEF Joint Statement;

- Collect and translate into your language up-to-date information on breastfeeding and breastfeeding management skills;

- Organise a breastfeeding study day at your institution;

- Offer to lecture on breastfeeding to student doctors, nurses or midwives; pharmacists and general practitioners at least once a year;

- Invite a representative of a Mother Support Group (MSG) to speak to your staff;

- Invite MSGs to meet at your institution or organise a MSG yourself. Your staff will learn from the mothers;

- Invite a representative of UNICEF or WHO to talk about the Baby Friendly Hospital Initiative;

- Organise a study trip to a baby-friendly hospital if there is one nearby;

- Invite a breastfeeding promotion group representative to talk about the WHO Code;

- Discuss offering your staff an intensive breastfeeding management programme or offer your institution as a site for a regional training programme;

- Prepare written breast feeding protocols with your staff and arrange regular in-services to discuss them. Have a monthly or regular evaluation session with staff on the practical aspects of breastfeeding promotion;

- Include breastfeeding news in an in-house newsletter.

Goals for health worker training

- Train all health workers especially nurses to be lactation initiators. The UNICEF 18-hour course; Breastfeeding Management and Promotion in a Baby-Friendly Hospital is a good model. Alternative
courses should incorporate all Ten Steps to Successful Breastfeeding, basic breastfeeding management and the application of the Internation Code of Mar keting of Breastmilk Substitutes within the hospital setting.

- Listening skills are a very important component of communication between the healthworker and the mother. They need to be included in healthworker training if mothers are to have the information and
support they need to acquire skill and confidence in breastfeeding their babies.

- Include breastfeeding management in all health worker education.

- Provide scientifically documented training materials by establishing a lactation resource centre within your institution.

- Continue on-the-job and refresher courses in breastfeeding management for everyone who has contact with mothers and babies (include housekeeping staff).

- Provide regular opportunities for staff to discuss doubts and concerns about breastfeeding practices in their institution.

- Involve staff at all levels in planning for implementation of practices which support breastfeeding.

- Train staff to teach expectant and new mothers about breastfeeding.

- Inform health workers about the risks to breastfeeding that the infant formula industry poses.

- Train health workers in their responsibilities for adhering to the International Code of Marketing of Breastmilk Substitutes.

This activity sheet has been prepared by Elizabeth Hormann for the World Alliance for Breastfeeding Action (WABA). This activity sheet is part of a series from WABA to assist groups with their activities to protect, promote and support breastfeeding and in particular, to provide action ideas that could be focused on World Breastfeeding Week, August 1st to 7th.



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