Training and Program Delivery

In-Service Training for Facility-Based Health Care Providers Theme

The Sri Lankan National Strategic Plan for Maternal and Newborn Health 2012-2016’s strategic objective is to revitalize the Baby Friendly Hospital Initiative (BFHI) and introduce the revised BFHI guidelines.  Major activities planned:

  • Develop and ensure implementation and monitoring of the Baby Friendly Hospital Initiative;  
  • Train all the staff in maternity and newborn care units in the institutions with the 20 hour WHO/UNICEF Baby Friendly Hospital Initiative training course;
  • Establish a system for internal and external assessment and accreditation on BFHI;
  • Establish a formal BFHI implementation and monitoring committee to ensure regular functioning of Baby Friendly Hospital Initiative;
  • Monitor the Sri Lanka code for promotion, protection and support of breastfeeding and marketing of designated products in collaboration with Infant and Young Child Feeding (IYCF) Programme; and
  • Advocate for the implementation of maternity benefits and lobby for revisions when required.

As a result of this plan, the in-service breastfeeding training provided in Sri Lanka:

  • UNICEF/WHO Breastfeeding Counselling a training course (40 hour) – for institution and field staff, including Public Health Midwives - the “front line” health workers providing domiciliary care to women of reproductive age and children within the community;
  • IYCF (6 days) training for the field staff;
  • BFHI (20 hour course) for the institutional staff; and
  • Essential New-born Care Course (5 days) for the institutional staff

In addition, Sri Lanka has a Lactation Management Centre located in every specialist hospital that provides maternity services and newborn care.  They are supervised by the Neonatologist/Pediatrician in charge of the Special Care Baby Units and have a Medical Officer on site but the day to day running is managed by Nursing Officers.   Nurses are required to have either the 40 hour WHO/UNICEF Breastfeeding Counseling Course or the 20hr BFHI Course. These training programmes are run by the Family Health Bureau (FHB).  The service has two nurses available seven days a week from 7 am – 5 pm, in addition to telephone hotlines.  Any mother with problems breastfeeding may use the center for free, without referral letters or appointments.

References:

  1. Wickramasinghe, S. (2012). Lactation management centres: A step forward in successful breast feeding.Sri Lanka Journal of Child Health, 41(2).
  2. Chandradasa, L., & Rowel, D. (2014). National Programme to Protect, Promote, and Support Breastfeeding in Sri Lanka. Paper presented at the Experience with Protection of Breastfeeding in SUN countries in Asia, Webinar.
  3. Family Health Bureau, Ministry of Health, Sri Lanka. (2011). National Strategic Plan: Maternal and Newborn Health (2012-2016).

In 2016, the New Zealand Breastfeeding Alliance (NZBA) started offering on-line BFHI courses with a focus on initiation of breastfeeding and infant feeding:

1.BFHI Level One: for people who have no clinical role in infant feeding working in maternity settings (3 hours)
2.BFHI Level Two: for people working in maternity settings who may have a clinical role but for whom infant feeding is not their prime focus (6 hours)
3.BFHI Level Three: for people working in maternity settings who have a clinical role in supporting and working with pregnant women and new mothers (18 hours)

Baby Friendly Community Initiative (BFCI) Courses (with a broader focus on infant and young child feeding):

1.BFCI Level One: for people with no clinical role in infant and young child feeding who are working in the community (3 hours)
2.BFCI Level Two: for people working in a community setting, who may have a clinical role but for whom infant feeding is not their prime focus (6 hours)
3.BFCI Level Three: for people working in a community setting who have a clinical role working with pregnant women and women with infants or young children (18 hours)

BFHI/BFCI Level One: "Awareness" (no clinical or a limited clinical role, and having regular contact with pregnant women, mothers and their babies).
Level One health workers may include cleaning staff, reception staff, nursing aides or management team members.
Subjects covered in this course include:

  • The importance of breastfeeding
  • The importance of exclusive breastfeeding until six months of age
  • Ten Steps to Successful Breastfeeding.
  • The Seven Point Plan (BFCI only)
  • The protection of breastfeeding which includes the International Code of Marketing of Breast-milk Substitutes and subsequent relevant WHA resolutions.

BFI certification requires Level One Awareness students to complete the equivalent of one hour of education every year of employment. The education must encompass the mandatory subjects.

BFHI/BFCI Level Two: "Generalist" (clinical role but infant feeding is not the prime focus, a 'Generalist' staff member does not usually include midwifery; nursing or support staff who have direct clinical contact with the antenatal / postnatal women.)
Generalist staff (examples of who may be included: obstetricians, pediatricians, general practitioners, dietitians) require education which includes the following:

  • The importance of breastfeeding.
  • The importance of exclusive breastfeeding until six months of age
  • The Ten Steps to Successful Breastfeeding.
  • The Seven Point Plan (BFCI only)
  • The protection of breastfeeding which includes the International Code of Marketing of Breastmilk Substitutes and subsequent relevant WHA
  • The effect of medications administered on breastfeeding, lactation and the infant.
  • The importance of referral to a Specialist Level 3 or 4 staff member when a breastfeeding situation arises beyond their scope of practice.

BFHI requires a Level Two - Generalist health worker to have completed a minimum of 6 hours of infant feeding education since employment and prior to external assessment. Ongoing education of one hour every three years is then required on Breastfeeding Policy review. The education must encompass the mandatory subjects above.

BFHI/BFCI Level Three: Specialist (clinical role and assists, or advises, pregnant women and/or mothers with infants and young children on infant feeding)
A Level Three employee is most likely classified as clinical worker working in either a maternity facility (BFHI) or the community (BFCI) - a midwife, nurse, childbirth educator or perhaps support workers who work in a clinical capacity with mothers and their babies.

At the time of the BFHI or BFCI external assessment evidence must be provided to demonstrate that any Level Three Specialist member of staff has completed the mandatory requirement of 21 hours of infant feeding education and, following this, ongoing education should equate to a minimum of four hours of infant feeding education annually. This ongoing annual education includes a minimum of one hour of clinical education. A 30-minute Breastfeeding for Maori Women education session must be attended during a three to four yearly ongoing education period.

  • The mandatory 21 hours of education for Baby Friendly services includes:
  • The importance of breastfeeding.
  • The implications of unnecessary supplementation
  • The Ten Steps to Successful Breastfeeding
  • The Seven Point Plan (BFCI only) resolutions.
  • The protection of breastfeeding including the International Code of Marketing of Breast-milk Substitutes and subsequent relevant WHA resolutions.
  • The Artificial Feeding Policy and the care of the non-breastfeeding mother and her infant.
  • Breastfeeding for Maori Women which incorporates the Treaty of Waitangi.
  • Complementary feeding (BFCI only)
  • Three hours of supervised clinical education

The NZBA website also offers a webinar series by the Lactation Consultants of Australia & New Zealand (LCANZ) which cover a variety of topics relating to breastfeeding and allows trainees to ask LCANZ members questions.

Within the New Zealand maternity system, most women choose a lead maternity carer (LMC) to provide their antenatal, labor and birth, and postnatal care.  LMCs are regulated by the Primary Maternity Services Notice and they must sign an access agreement with the maternity facility.  Through this process, they are required to support the implementation and practice of the BFHI.   If the LMC is a midwife, which the majority are, they are regulated by the Midwifery Council of New Zealand and must attend a three-hour professional breastfeeding education session to be able to receive their annual practicing certificate. The Competencies for Entry to the Register of Midwives provide detail of the skills, knowledge, and attitudes expected of a midwife to work within the Midwifery Scope of Practice.

Midwives have their competence assessed at certain points:

  1. Upon registration as a midwife in New Zealand.
  2. Upon each application for an Annual Practicing Certificate.
  3. Upon return to practice after an absence of three or more years.
  4. At any other time on the decision of the Midwifery Council as a result of a notification of concern about a midwife's competence.

Competency 2.11 covers the Ten Steps to protect, promote and support breastfeeding.

References:

  1. New Zealand Breastfeeding Alliance Online Learning
  2. Midwifery Council of New Zealand. (2007). The Competencies for Entry to the Register of Midwives.

Other Resources

The WHO Breastfeeding Training course (Reference #1) consists of 33 sessions designed to provide health workers with the skills needed to support mothers and their children to breastfeed optimally. It includes guides for the course director, trainers and participants.  The course is a mixture of lectures, demonstrations, group work and discussion and clinical practice.  It is intended to take 40 hours, spread intensively over two days or spread out over a longer period.  An additional 40 hours, or 5 days is necessary for the preparation of trainers. This is best done in the week preceding a training course and enables trainers to become familiar with the course materials, and learn how to conduct the different kinds of sessions.

The sections include:

Session 1 Why breastfeeding is important
Session 2 Local breastfeeding situation
Session 3 How breastfeeding works
Session 4 Assessing a breastfeed
Session 5 Observing a breastfeed
Session 6 Listening and learning
Session 7 Listening and learning exercises
Session 8 Health care practices
Session 9 Clinical Practice 1

The Director’s Guide covers how to plan and conduct a course. It includes a course outline, instructions for necessary preparations and a description of the facilities, materials, and equipment needed:

  • Introduction – aims, structure and materials needed
  • Planning and administration - selecting participants and trainers, timetable, funding
  • Preparation of Trainers – methods and materials 
  • Director's role during the course – supervision, monitoring and evaluation
  • Planning course follow-up activities
  • Checklists, forms and timetables

The Trainer’s Guide is a comprehensive manual covering all 33 sessions of the
Course and contains all the information needed, with detailed instructions on how to conduct each session. It describes the teaching methods used, and includes all exercises together with suggested answers. It also contains practical guidelines, summary boxes, forms, lists, and checklists; and the stories used during the course. At the end is a short list of key textbooks, and a list of papers which are additional sources of information about points made in the
presentations.

The Participants' Manual is the main guide to the course and contains:

  • summary of the main information from each session, including descriptions of how to do each of the skills
  • copies of the key pages for memorization
  • forms, lists and checklists for exercises and clinical practice
  • written exercises for individuals

The revision of the original WHO/UNICEF 18 hr BFHI course in 2009 took into account new research on supportive practices (Reference #2).  The Breastfeeding Promotion and Support
in a Baby-friendly Hospital: a 20-hour course for Maternity Staff is intended to help equip hospital staff with the knowledge and skill base necessary to transform their health facilities into baby-friendly institutions through implementation of the Ten Steps to Successful Breastfeeding, and to sustain policy and practice changes.

The training materials are guidelines for experienced course facilitators and are not intended as a word-by- word course. It focuses on the application of the health workers’ knowledge and skills in their everyday practice rather than providing a large amount of theory and research.  The course entails 15.5 hours of classroom time focused on skill-oriented training including discussion and pair practice and 4.5 hours of clinical practice.

Topics :

Session 1: BFHI: a part of the Global Strategy
Session 2: Communication skills
Session 3: Promoting breastfeeding during pregnancy – Step 3
Session 4: Protecting breastfeeding
Session 5: Birth practices and breastfeeding - Step 4
Session 6: How milk gets from breast to baby
Session 7: Helping with a breastfeed - Step 5
Session 8: Practices that assist breastfeeding – Steps 6, 7, 8, & 9
Session 9: Milk supply
Session 10: Infants with special needs
Session 11: If baby cannot feed at the breast – Step 5
Session 12: Breast and nipple conditions
Session 13: Maternal health concerns
Session 14: On-going support for mothers – Step 10
Session 15: Making your hospital baby-friendly
Clinical practice 1 - Observing and assisting breastfeeding
Clinical practice 2 - Talking with a pregnant woman
Clinical practice 3 - Observing hand expression and cup feeding
Appendix 1: Acceptable medical reasons for use of breast-milk substitutes
Appendix 2: Knowledge Checks

References:

  1. World Health Organization. (1993).  Breastfeeding Counselling: A Training Course.
  2. World Health Organization, UNICEF. (2009).  Breastfeeding Promotion and Support in a Baby-Friendly Hospital: A 20-Hour Course for Maternity Staff.

The Ministry of Health of Viet Nam developed their IYCF training program based on WHO, UNICEF and Alive & Thrive training material. Feedback was provided by the Professional Certification Committee, the National Institute of Nutrition (NIN), obstetrics and pediatrics experts, specialists from WHO, UNICEF, representatives of health workers in maternal and child health care at all levels across the nation, and with technical and financial support from A&T.

The 40 sessions, including 25 theory sessions and 15 practicals, are focused on breastfeeding and complementary feeding. The training duration is 5 days with 8 periods a day and each period is 50 minutes. All the essential topics in Annex 3 and 4 are included in this training manual, with the exception of contraception. These manuals provide IYCF knowledge and skills according to WHO’s recommendations and Vietnam’s context. Appendices include information for reference, illustrations and existing documents related to IYCF.  Countries can adapt this training to their own country context.

The use of constructive teaching/ learning methods should be based on trainees’ needs and the manual provides different appropriate methods to achieve the training objectives and practical context.  These include: Presentation with illustration, Problem-presenting, Problem-solving, Brainstorming, Studying materials, Case-studying, Group discussion, Role-playing, Demonstration, Practicing, Teaching/learning on procedure, and Clinical teaching.  The package contains the Training Program, Trainer’s Manual and Trainee’s Manual.

Evaluation:

  • Pre- and post-test questions: for use with each session (questions and answers are at the end of each section in the Trainee’s Manual);
  • Examination papers/tests: use the pre- and post-test question bank to design the examination paper and test to meet the training objectives;
  • Evaluation method and form: select in accordance with the training objectives to be evaluated (Theory, practice);
  • Quick knowledge assessment during the training process - using post-tests and case study results;
  • Assess skills using checklists and score cards in role-playing practice sessions (checklists are at the end of each section in the Trainees Manual);
  • Evaluation score/ timing:
    • Regular evaluation score - use the quick assessment results during the training process (case study results during practice sessions and post-test results);
    • End-of-course training evaluation score - an overall examination paper.
  • Evaluation result: average score of the regular evaluation score and the end-of-course training evaluation score.

Certification:
Trainees are provided with certificates when they meet the following requirements:

  • Evaluation result for the whole training course is not below 5 points;
  • Participating in no less than 70% of the training duration, with trainer’s permission
    for the absence time.

Training Program (each topic has a specified duration for theory and practice time): 

  • Overview of Infant and Young Child Feeding 
  • Importance of Breastfeeding 
  • Breast Milk Production 
  • Positioning and Attachment 
  • Expressing and Storing Breast Milk 
  • Practicing Ten Steps for Successful Breastfeeding at Health Facilities 
  • Common Breastfeeding Difficulties 
  • Breastfeeding Low Birth Weight Babies 
  • Nutrition and Health Care for Pregnant Women and Lactating Mothers 
  • International Code and Vietnam’s Regulations on the Trade in of Nutritious Products for Infants and Young Children 
  • Inter-personal Counseling Skills 
  • Individual and Group Counseling 
  • Field Practice at Hospitals on Counseling and Giving Instructions on Breastfeeding 
  • Importance of Complementary Feeding 
  • Complementary Foods 
  • Quantity and Quality of Complementary Feeding 
  • Fussy Eating and Refusal to Eat in Children 
  • In-classroom Practice: Counseling and Giving Instructions on Complementary Feeding 
  • Feeding Children during Illness and Recovery and Children with HIV- infected Mothers 
  • Assessing Nutritional Status of Children

Reference:

The 16-Hour Birth and Beyond California (BBC) Learner Workshop is designed to provide healthcare workers, including physicians, nurses, lactation educators, and others in routine contact with mothers, with the knowledge and skills to support a mother’s decision to breastfeed.  This workshop, ideally given by a team of at least two trainers, is interactive.  It includes PowerPoints and activities for staff participants before they practice parent-infant attachment.  The BBC Curriculum was developed as a result of collaboration among the California Department of Public Health (CDPH), Maternal, Child and Adolescent Health (MCAH) Division and local organizations/individuals, including breastfeeding coalitions, IBCLCs, public health scientists, nutritionists, and hospital associations.

The 12 individual modules in PowerPoint format have detailed speaker’s notes on each slide but pictures are not included. The listing of photos used in the staff training can be found in the BBC Photo Bibliography.  The slides also refer to videos which can be purchased separately (see the list below) or can be replaced with free versions available on-line, like the Global Health Media website http://globalhealthmedia.org/.

The topics cover some of Annex 3 and 4, such as factors that influence breastfeeding, promotion of initial breastfeeding, milk production, the benefits of breastfeeding, technical guidance and common problems, as well as an observation of a mother nursing.  The emphasis of this training program is to promote attachment and skin to skin contact to increase breastfeeding rates.

BBC Learner Workshop Modules and corresponding handouts:
Module 00: Introduction (PPT)
            Handout: Eating Pattern Activity (word document)
Module 01: Science of Attachment (PPT)
Module 02: Anatomy & Physiology (PPT)
Module 03: Promoting Breastfeeding & Risk of not Breastfeeding (PPT)
            Handouts:
            Doing Both (PDF)
            Feeling Word Activity (PDF)
            Agency for Healthcare Research and Quality, U.S. Department of Health and Human        Services 2007 Executive Summary (PDF) – a review of the evidence on the effects of       breastfeeding on short- and long-term infant and maternal health outcomes in    developed countries
            The Role of Human Milk (Word document)
Module 04: Predictable Newborn Patterns Presentation (PPT)
            Handouts:
            Baby’s Second Night (PDF)
            Eating Patterns Activity (Word document)
            Feeding Activity Chart (PDF)
Module 05: Hospital Practices Presentation (PPT)
            Handout: Hospital Practices Influence Breastfeeding (PDF)
Module 06: Putting Baby to Breast (PPT)
Module 07: Assessment and Documentation of Feedings (PPT)
            Handout: Latch Assessment (Word document)
Module 08: early Breastfeeding Concerns (PPT)
            Handouts:
            Belly Ball Cards (PDF) – thistool is for new parents to visualize the size of their    newborn’s stomach and how much milk it can hold at birth. It is designed to reinforce         that supplements are not needed and that colostrum is more than enough to meet a       newborn’s needs.
            Belly Balls Descriptions (PDF)
Module 09: Expressing and Feeding Breast Milk (PPT)
            Handouts: Storage Guidelines (PDF)
Module 10: Special Situations (PPT) - preterm, late preterm babies            , hypoglycemia,           hyperbilirubinemia (jaundice), medications and milk
            Handout: Preemie Wheel (PDF) - a visual reminder of the sequential steps that a baby    must go through before achieving exclusive feeding at the breast.
Module 11: Continuity of Care (PPT)
Module 12: Sustainability (PPT)
            Handouts:       
            Bibliography (PDF)
            Clinical Competency (Excel)

Evaluation Tools for the Learner Workshop

  • Participant Self-Efficacy Scale (PDF)
  • Pre-Test (PDF)
  • Post-Test (PDF)
  • Pre-Post Key (PDF)
  • Evaluation Forms: Day 1 and Day 2 (PDF)

Videos
"Kangaroo Mother Care I & II” By Nils Bergman, MD
“Clinical Implications of Touch in Labor and Infancy” By Marshall Klaus, MD, Stephen Suomi, MD
“Six Core Strengths for Healthy Childhood Development – Attachment” By Bruce Perry,
“Six Core Strengths for Healthy Childhood Development – Self-Regulation” by Bruce Perry
“Your Baby Knows How to Latch On” By Ameda
“Amazing Talents of the Newborn” By Marshall Klaus, MD
“Breastfeeding: Baby’s Choice”
“Latch 1, 2, 3”
“Helping a New Mother to Breastfeed” by Royal College of Midwives
Note: This video is currently only available in VHS and for sale in the United Kingdom only.
“Breastfeeding Management, Teaching Tools for Physicians and Other Professionals” by Jane Morton, MD
“A Preemie Needs His Mother” By Jane Morton, MD

Reference:

This article in the journal African Health Science documents three examples of health professionals rejecting funding, gifts and free seminars from formula companies in three countries.  They illustrate the challenges for low to middle income countries, where health workers are vulnerable to lucrative come-ons and are not necessarily aware of the dangers posed by the aggressive marketing strategies of these companies.  Training for all health workers should include specific guidance on monitoring and reporting violations of the International Code and rejection of seminars, gifts and incentives offered by the formula industry.

Reference:

  1. Brady, J. P., & Srour, L. (2014). India, Laos and South Africa reject sponsorship and gifts from formula companies.Afr Health Sci, 14(1), 211-215. doi:10.4314/ahs.v14i1.33

In-Service Training for Community-Based Health Care Providers Theme

In Sri Lanka, community level maternal and child health care delivery is done by Public Health Midwives (PHM). The PHM is the “front line” health worker providing domiciliary care to women of reproductive age and children within the community. Each PHM has a well demarcated geographic area with a population ranging from 3000 to 5000 and maintains a register for all eligible females (eligible couple’s register) in the reproductive age and families with children less than 5 years. This enables the PHMs to provide a continuum of care commencing before pregnancy. Through systematic home visits and clinic sessions they provide domiciliary services to pregnant women, post-partum women, newborns and children under five, and clinic services and community level health activities such as group health awareness and promotion. They provide antenatal education and postnatal counseling, including improving breastfeeding skills, problem identification, intervention and referral. The PHM is a member of the health team providing MCH services at field and institutional clinics and links the domiciliary services at community level with clinic and institutional care. All PHMs undertake the 40 hr WHO/UNICEF breastfeeding counseling training program. 

References:

  1. Agampodi, S. B., & Agampodi, T. C. (2008). Effect of low cost public health staff training on exclusive breastfeeding.The Indian Journal of Pediatrics, 75(11), 1115-1119.
  2. Family Health Bureau, Ministry of Health, Sri Lanka. (2011).  National Strategic Plan: Maternal and Newborn Health (2012-2016).

In-Service Training for Community Health Workers and Volunteers Theme

In Afghanistan, breastfeeding training is integrated into the wider national public health training program for the Afghan CHWs.  The CHW is the primary or first level of health workers of the Afghan Health Care System. Their main task is to promote a healthy community through healthy behaviors and a healthy environment. They also encourage use of the local health facility for preventive health services. They treat common health problems and recognize life threatening problems that need referral. The CHW serves 100 –150 families within his/her own community. In isolated and remote areas with scattered populations, one CHW will serve 30 – 50 families. 

The CHW Manual and curriculum (Reference #1) were developed through consensus workshops with the MOH, UNICEF, WHO and other NGOs and the specific focus of this community-based health care system is on child and maternal health.  CHWs collaborate with and support community midwives and promote good nutrition though encouraging early and exclusive breastfeeding for six months.
This manual provides an overview of the roles and responsibilities of CHWs in meeting the health needs of the population, as well as key information and skills the CHWs require. Each chapter includes sections on: background, things to know, things to do and key points. The health topics covered: personal and home hygiene, safe food and water, immunization, nutrition, preventing common infectious diseases, maternal, newborn and child health, family planning, nutrition, HIV/AIDS, TB, first aid and mental health. The training manual also addresses key skills for CHWs, such as basic assessment and diagnosis, referral, communication, community mapping, household surveys, and basic drug administration. The topics are based on the Basic Package of Health Services, the Community Based Health Worker Policy and the National Health Policy of Afghanistan.
Breastfeeding Sessions:

  • Background
  • Things to Know
  • Breast milk is the best method for feeding babies and small children
  • during the first 2 years of life
  • How long should a Baby Breastfeed?
  • How to Breastfeed
  • Common Worries and Problems
  • Pain and Swelling in the Breasts
  • Things to Do
  • Key Points

USAID developed a training manual to help CHW Trainers in Afghanistan undertake the postpartum family planning (PPFP) training course for new CHWs (Reference #2). It does not replace the CHW manual referenced above, but is an addition to the CHW’s responsibilities and provides more in-depth information on family planning, including breastfeeding.
This training package promotes a training approach based on the principles of adult learning,
which is participatory, relevant, and practical. Adult learning principals are based on the following assumptions:

  • The trainees are interested in the topic;
  • The trainees wish to improve their knowledge, skills, and job performance; and
  • The trainees desire to be actively involved in course activities.

To be effective, trainers must use appropriate “hands‐on” training techniques, which are emphasized in this training package.

CHWs provide one antenatal and four postnatal visits to the pregnant/post-partum mothers to provide counseling and care in PPFP. During the antenatal visit (at 8-months pregnant), the CHWs key messages to the mother include the benefits of breastfeeding and encouragement to initiate immediately after birth.

The manual includes practical demonstrations and role play, as well as group exercises and skill-based training on decision making, counseling and negotiation. All the essential topics in Annex 3 and 4 of the BFCI manual are covered, with the exception of nutritional needs of the breastfeeding mother, breastfeeding during sickness and responsibilities under the Code.  However, the training emphasizes the disadvantages of formula feeding and the benefits of breastfeeding.  There is extensive material provided on contraception. Nutrition is covered in the Community Health Worker Training Manual above.

Topics covered
Interpersonal Communication and Counseling, Attitude and Negotiation (IPCCAN):

  • Concept of communication for behavior change
  • How to improve communication
  • How to conduct interpersonal communication and counseling (ipc) sessions: one to one and group sessions
  • Concept of counseling, principles of counseling and qualities of good counselor
  • Steps of counseling: listening and learning
  • Steps of counseling: building confidence and giving support

Breastfeeding:

  • Importance of breastfeeding
  • Basics of breastfeeding
  • Techniques of breastfeeding.
  • Expressing breast milk
  • Common breastfeeding difficulties
  • Counseling points on breastfeeding

Basic lam concepts and providing lam services
Healthy timing and spacing of pregnancy
Family planning methods
Ipc, advocacy and group meeting:

  • Counseling guideline
  • Advocacy and group meeting

These two training manuals cover all the essential topics in Annex 3 and 4 of the BFCI manual, with the exception of breastfeeding during sickness and responsibilities under the Code.

References:

  1. General Directorate of Preventive Medicine and Primary Health Care, Community Based Health Care (CBHC), Department Ministry of Public Health. (2005).  Islamic Republic of Afghanistan Ministry of Public Health Community Health Worker Training Manual.
  2. USAID. (2008).  Community Health Worker Postpartum Family Planning Training Package for CHW Trainers.

A study by Mannan et al. (Reference #1) tested a community-based intervention in Bangladesh in which community health workers (CHWs) made home visits in the first week after delivery, assessed breastfeeding techniques, provided counseling and hands-on support to establish successful breastfeeding.  The CHWs had..."21 days of classroom, hospital and community-based training on essential newborn care, which included an 8-h module on breastfeeding counseling and support, followed by a 6-h practical session on observation and assessment of breastfeeding and a 4-h practical session on counseling in the community, totaling approximately 2.5 days. Topics covered included the following: (i) importance and basic features of breastfeeding, (ii) techniques of breastfeeding, (iii) milk expression, (iv) common problems of the breasts during breastfeeding and (v) counseling points on breastfeeding. Training methods included lectures, hands-on demonstration and practical exercises with real-life postpartum breastfeeding mothers and video-guided lessons." A trainer evaluated each CHW and provided refresher training when necessary. 

During each visit, CHWs were trained to undertake an assessment of how breastfeeding was progressing, including correct positioning and attachment, frequency, and any difficulties (See Table 1 for an example of the assessment form).  Based on their assessment, CHWs were trained to help mothers with any issues, including practical, hands-on help, and encourage exclusive breastfeeding.
Bangladesh has a history of using CHWs to support health services. BRAC has been a driving force and the focus has been on female CHWs, often illiterate, who were oriented to health promotion and disease prevention. The Shasthya Shebika (SS) Program is rooted in a gendered perspective, focusing on the need for female health workers in Bangladesh to address socio-cultural barriers to access to health care services.
Bangladesh has approximately 100,000 CHWs through the SS Program, run through BRAC.  SSs receive 4 weeks of basic training at the local BRAC office covering common medical conditions, promotion of healthy behaviors and to refer cases as appropriate.  This training includes promoting exclusive breastfeeding and duration of breastfeeding beyond introduction of complementary foods.
Direct supervision is conducted by higher-level CHWs called shasthya kormis (SKs), who, like the SSs, are recruited from their communities. SKs are paid a sum equivalent to about $40 per month to supervise the SSs and perform antenatal care in villages. The SKs, all women, have a minimum of 10 years of schooling and work between 4 and 5 hours per day. They accompany each of the SSs in their charge on community visits at least twice per month and meet monthly with their group of SSs to discuss problems, gather information, and provide supplies and medicines. BRAC program staff members also participate in supervision. There is a formal link to the local government’s health service delivery system for referral when necessary.

SSs earn an income from selling supplies such as oral contraceptives, birthing kits, iodized salt, condoms, essential medications, sanitary napkins, and vegetable seeds at cost plus a small markup. They receive incentives for good performance that are based on achieving specific objectives during that month, such as identifying pregnant women during their 1st trimester. Supervisors verify and monitor performance during their visits to communities, where they have the chance to talk with village women.  Like most other program activities at BRAC, the SS Program is subsidized by income-generating activities that BRAC operates at scale, including commercial enterprises in handicrafts, milk and poultry production, printing, and banking.
In 2011, the Institute of Public Health Nutrition developed an IYCF training manual, in consultation with the IYCF Alliance, relevant institutes, scientist, public health experts, nutritionists, development partners and various organizations operating in Bangladesh, and is rooted in the results of surveys and formative research undertaken.  (Reference #3)

The audience is all health workers involved with infant and young child feeding in Bangladesh and was used to train BRAC’s existing cadre of CHWs - 11,000 frontline workers and supervisors. The language is purposefully easy to understand and accessible to all level of professionals and workers. 

Methods:

  • Lecture
  • Video on breastfeeding and complementary feeding
  • Discussion,
  • Hands-on training
  • Role play
  • Practical sessions
  • One-to-one counseling practice
  • Experience sharing,
  • Practice in the community counseling mothers

Structure: Each classroom session includes an introduction, learning objectives, participatory
methodologies, and activities. For the field work, one facilitator supervises 5-6 participants. Pre- and post-tests and feedback sessions on the training are conducted at the start and end of the sessions.
Time: 3 days in the classroom and 3 days in the community to practice counseling.

The course content draws from the WHO/PAHO Guiding Principles for Complementary Feeding of the Breastfed Child (2003), WHO’s Infant and Young Child Feeding Counseling: An Integrated Course (2006), and AED’s Essential Nutrition Actions training module. These materials were adapted for use with frontline workers in Bangladesh.

Alive & Thrive (A&T) also have two training videos, a 16-minute video on breastfeeding that shows good positioning and attachment and breastmilk expression as well as an 18-minute video on complementary feeding.

Topics:
Session 01 - Introduction to the training
Session 02 - How to improve performance of health workers
Session 03 - Importance of breastfeeding and breastfeeding recommendations
Session 04 - Position, attachment and manual expression of milk during breastfeeding
Session 05 - Video on breastfeeding (position, attachment and manual expression of breast milk)
Session 06 - Breastfeeding difficulties and how to address them
Session 07 - Maternal nutrition during pregnancy and lactation
Session 08 - Introduction to job aid and observation checklist for exclusive breastfeeding
Session 09 - Counseling and role play for breastfeeding
Session 10 - Counseling practice for breastfeeding at health facilities/field level

Skills topics:

  • Providing IYCF support at community and household level
  • Identifying and managing feeding difficulties
  • Negotiating improved practices to help mothers identify and resolve problems
  • Counseling, coaching, and demonstration skills
  • Helping mothers by showing positioning and attachment to support exclusive breastfeeding
  • Demonstrating preparation of home-based complementary foods

This training manual covers all the essential breastfeeding topics in Annex 3 and 4 with the exception of contraception and maternal absence.

As part of A&T’s interpersonal communication strategy and in support of the National IYCF Strategy, they implemented a training program, using the national IYCF training manual, to build on the existing skills and abilities of BRAC’s cadre of community health workers and volunteers.   Working with the MOH, BRAC and other NGOs, the key messages decided on by the IYCF Alliance (formative research revealed that mothers thought that their milk was insufficient and complained that their young children had poor appetite on breastfeeding) were communicated to 11,000 CHWs through BRAC’s training program.

In 2009 Alive & Thrive set a target of reaching, by 2013, 3.5 million children under 2—almost half of the country’s children in that age bracket—through intensive community interventions.
They facilitated simultaneous trainings at multiple venues and developed a single pocket-size job aid that the IYCF alliance members recommended. The program was rolled out in stages, ensuring adequate time to test innovations, such as performance-based incentives for volunteers.

To reach these targets, BRAC had to train more than 11,000 frontline workers and supervisors. Using 5 of BRAC’s training sites, they had trained workers from only 22 of the 50 set districts in 9 months so they decided to use 11 additional BRAC training sites.  With that adjustment they managed to train up workers for the remaining 28 sub-districts in only 6 months.

The interpersonal and community mobilization component of A&T’s program is based on the belief that the more times and the more ways a family is “touched” with the same messages, the more likely they are to adopt recommended practices. The numbers below cover a single month of program activities in the 50 BRAC Alive & Thrive program sub-districts in Bangladesh:
405,800 - Home visits by frontline workers
3,000 - Number of community mobilization session attendees
153 – Community mobilization sessions
25,000 - Estimated phone contacts
27,315 - Health forums
38,500 - Number of health forum attendees (all women)
37,400 - Mothers counseled on breastfeeding during antenatal care

A&T’s evaluations midway through the project found that in their project areas, 85% of all mothers interviewed in 2013 reported that a frontline worker had visited the home and talked with them about infant and young child feeding, compared with 21% in comparison areas.

CHWs are assigned to 250-300 households in her neighborhood. Based on the A&T child survey, approximately 10 to 12% of all households have children under 24 months of age - roughly 35-40 children per service area covered by the CHW. The primary focus of the CHW is households with pregnant and postpartum women, but her broader responsibilities include outreach to other households in the community. All frontline health care workers receive the same basic training in breastfeeding and complementary feeding and are held accountable for coverage and behavior change results.

There are four core interventions of the Alive & Thrive IYCF Community Model:

  • Home visits - community volunteers, community health workers, and IYCF promoters provide mothers of children 0-24 months of age IYCF counseling, coaching, demonstrations, problem-solving, and referrals
  • Antenatal care sessions and postnatal care visits - frontline workers discuss early initiation of breastfeeding and exclusive breastfeeding and provide support for good positioning and attachment
  • Health forums -frontline workers include IYCF messages and issues in small group discussions with pregnant women, mothers, and family members
  • Social mobilization sessions- to raise awareness of IYCF and seek commitments to action by influential members of the community.

Critical to the effective delivery of the four interventions:

  • Human resources
  • Basic and refresher training
  • Supervision and coaching
  • Performance evaluation and incentives
  • Measurement, learning, and evaluation.

Within the implementation manual, there are annexes covering a map showing program locations, a list of sites, brief descriptions of training modules and orientation sessions, performance checklists, a course schedule, monitoring instruments, and reporting formats

A&T provides four types of training:

Training of Trainers
35 master trainers were selected from BRAC’s Health Program Training Unit. They are experienced trainers who are qualified to train frontline workers. The curriculum to
train the master trainers is the same one used in training staff and frontline workers, but the topics are taught in more depth. The training lasts 6 days.

Basic IYCF Training
The community volunteers, community health workers, IYCF promoters, program organizers, and monitors attend 3 days of classroom training. The community health volunteers then receive 1 day of field practice supervised by a trainer who observes her counseling a mother of an infant less than 6 months old on breastfeeding and counseling a mother of an older infant on complementary feeding. The field practicum involves individual, supervised practice with mothers in selecting and negotiating 2-3 key practices as well as demonstrations of recommended practices such as preparing foods of the proper consistency for an older infant, practicing responsive feeding, positioning and attaching the baby to the breast, and expressing breastmilk.

The CHWs and IYCF promoters receive 3 days of field practice. During the first day, the trainer
observes them counseling. During the other 2 days of field practice, they are teamed with a trainer and observe and provide feedback to 2 community health volunteers trainees each day.
The ratio of trainer to trainees is 1 to 6. The training covers essential information to increase knowledge of IYCF, includes demonstrations of desirable practices, and provides opportunities to practice key skills.

Interpersonal counseling is a critical component of the IYCF Community Model and features prominently in the training. The guidelines for interpersonal counseling that are taught in the training are listed in annex 6.

Monthly Meeting and Refresher Training
One day a month the community health workers, community health volunteers, and IYCF promoters come together for a meeting.

Facilitators cover the following:

  • Distribute commodities
  • Pay incentives
  • Review progress
  • Give feedback from the observation checklists on the frontline workers’ performance and ability to reach their target population
  • Exchange of lessons learned
  • Planning for the next month
  • Providing refresher training, as needed, on any health topic
  • Introduce new topics
  • Fill knowledge gaps, and/or solve problems identified during the monthly observation by supervisors

In late 2011 A&T introduced special refreshers for the volunteers and the IYCF promoters focused only on IYCF-related issues. The program organizers and more skilled IYCF promoters in the sub-district conduct these sessions, which are held four times per year at the BRAC sub-district office. This special 6-hour refresher training can include demonstrations in counseling and coaching and in areas that remain challenging for some frontline workers.

Orientation for Traditional Birth Attendants (TBAs)
The four-hour orientation session for TBAs aims to give them the information and skills they need to help mothers practice early initiation of breastfeeding and exclusive breastfeeding for 6 months.

Topics covered:

  • Importance of early initiation of breastfeeding and avoidance of prelacteals
  • Importance of exclusive breastfeeding
  • Signs of good positioning and attachment
  • Expression of breastmilk for feeding low birthweight babies
  • Maintenance of exclusive breastfeeding (how to maintain or increase supply and assess if supply is adequate)
  • Role of TBAs in building mothers’ confidence in their ability to exclusively breastfeed for 6 months
  • Myths and misconceptions e.g., small breasts cannot produce enough milk, food prohibitions for lactating women, and stopping breastfeeding because the baby or mother is sick

The session includes: discussion (facilitated group), skills practice, and a video on
positioning, attachment, and breastmilk expression. Participants use dolls to practice wiping, wrapping, and placing a baby to the breast as quickly as possible and positioning the baby to the breast. They use a dummy breast or orange to practice manual expression of breastmilk.

References:

  1. Mannan, I., Rahman, S. M., Sania, A., Seraji, H. R., Arifeen, S., Winch, P., . . . Baqui, A. (2008). Can early postpartum home visits by trained community health workers improve breastfeeding of newborns?Journal of Perinatology, 28(9), 632-640.
  2. Henry Perry, R. Z., Kerry Scott, Dena Javadi, and Jess Gergen. (2013). Case Studies of Large-Scale Community Health Worker Programs: Examples from Bangladesh, Brazil, Ethiopia, India, Iran, Nepal, and Pakistan.
  3. Institute of Public Health Nutrition, Directorate of Health, Ministry of Health and Family Welfare, Bangladesh. (2011). National Training Manual on Infant and Young Child Feeding.
  4. Alive and Thrive. (2013).  Implementation Manual for BRAC’s Community-based Alive & Thrive Infant and Young Child Feeding Program in Bangladesh.
  5. Alive & Thrive. (2014).  Getting strategic with interpersonal communication: Improving feeding practices in Bangladesh.

World Vision's Timed and Targeted Counselling for Health and Nutrition (ttC) is a comprehensive training course for CHWs and volunteers working in maternal and child health (Reference #1). ttC combines Behavior Change Counseling (BCC) at the household level with a life-cycle approach from pregnancy through to the second year of life, with a comprehensive package of manuals, job aids, trainers’ guides and planning tools.  The second edition builds on their global field experience with ttC. 
ttC is designed to be delivered by CHWs, who are formally or informally linked to the local health authorities and recognized by the Ministries of Health. However, in some contexts, the appropriate cadre can be community group volunteers such as Care Groups, traditional birth attendants (TBAs), or other non–CHW cadre and so the materials use the term ttC-Home Visitors (ttC-HVs).

Promotion of early initiation of exclusive breastfeeding is one of the technical components of the training and whilst this training package does not contain the essential topics in Annexes 3 and 4 of the BFCI, it is a useful resource for countries who want to incorporate effective communication to promote behavior change.  This material may help health workers understand why providing information is not necessarily sufficient to change someone’s behavior – it is intended to clarify the differences between knowledge, beliefs and actions, how to respond appropriately to barriers and to learn better ways of communicating.

Facilitator’s Manual for Training in ttC - step-by-step guidance for conducting the CHW training. This manual has all of the information contained in the ttC Participant’s Manual, in shaded boxes.

Trainer’s Guide - This guide should be used by certified trainers to instruct facilitators who will go on to train ttC-HVs.
Unit 1: ttC Training of Facilitators (ToF) Course Design, Competencies and Assessment
Unit 2: Preparation for the ttC ToF Event(s)
Unit 3: Conducting the ToF -  including a class timetable.   
Unit 4: ttC Certification and Evaluation of Learning

Participant’s Manual- summarises all the technical content and is a one-stop reference for literate ttC-HVs. For work in low literacy contexts, consider excluding this material or provide it only for ttC-HV supervisors.

Sessions:
1: Introduction to timed and targeted counselling
2: Understanding the health and nutrition problems in the community
3: Identifying pregnant women in the community
3b. Registration of eligible women and girls
4: Behavior change
5: Communication skills
6: Psychological first aid skills and maternal well-being and support
7: The dialogue counseling approach
8. Negotiation using of the household handbooks

In a review of existing training resource materials for CHWs by Tran et el., they found that World Vision’s ttC package provides a more comprehensive CHW supervision manual than most, incorporating critical elements of supervision such as, assurance, performance evaluation and feedback, and integration of existing community structures to oversee the activities of CHWs (Reference #2). The other two packages with comprehensive supervisory elements are the Millennium Villages Project Community health worker trainer’s manual and the WHO/UNICEF Infant young child feeding counselling: an integrated course.

This paper aimed to identify, organize and provide a synthesis of training on different components of sexual and reproductive, maternal, newborn, child, and adolescent health (SR/MNCAH) and to determine gaps and opportunities and inform efforts to avoid duplication and harmonize approaches to training CHWs in SR/MNCAH.

The authors mapped the inclusion of capacity development, specifically the continuous process of strengthening knowledge and skills that requires follow-up and supportive supervision of trainees beyond the actual training session.  The Alive and Thrive program in Bangladesh incorporated monthly meetings with refresher training as one of its core elements.

The results of this mapping of training resource packages for CHWs are as follows:

  • Technical content needs to be regularly updated and aligned with global guidance, especially in rapidly evolving areas;
  • High standard guidelines for the supervision and quality assurance of CHW activities are lacking;
  • Ongoing training, support, and supervision of CHW is critical;
  • Integration of CHWs into community health systems is weak; and
  • Cross-sectoral integration of CHWs as part of the overall health system needs strengthening.

Countries looking to improve their community-based health worker training should ensure their training packages incorporate these key issues.

References:

  1. World Vision International. (2014). Timed and Targeted Counselling for Health and Nutrition, 2nd Edition: A Comprehensive Training Course for Community Health Workers.
  2. Tran, N. T., Portela, A., de Bernis, L., & Beek, K. (2014). Developing capacities of community health workers in sexual and reproductive, maternal, newborn, child, and adolescent health: a mapping and review of training resources.PLoS One, 9(4), e94948. doi:10.1371/journal.pone.0094948

The Global Health Media Project designs and develops videos that are tailored to the needs of health workers and populations in low-resource settings. Internet and mobile technology means reaching large numbers of people in a cost-effective way. These short videos provide a simple and effective solution to help health workers and communities gain the knowledge and basic skills that can save people’s lives.  They employ simple and easy to follow visual steps that can be accessed on any device.

The Breastfeeding Series used the following sources:

  • Dr. Jack Newman’s Guide to Breastfeeding, Jack Newman and Teresa Pitman, 2014
  • Breastfeeding Made Simple, Nancy Mohrbacher and Kathleen Kendall-Tackett, 2010
  • Breastfeeding Promotion and Support in a Baby-Friendly Hospital: 20-hour Course, UNICEF/WHO, 2009
  • Lactation experts from around the globe.

Go to Global Health Media Project, Breastfeeding Series for the videos available free of charge for training and support purposes.  They can be downloaded and are available in English, French, Spanish, Swahili, Nepali, Lao, Khmer, Kinyarwanda, and Vietnamese and cover a range of topics, such as expressing, attaching, and early initiation.

Train the Trainers Theme

In Afghanistan, a training of trainers approach has been implemented to increase the number of qualified breastfeeding personnel.  A 2011 report on malnutrition in Afghanistan by Levitt et al. describes how this approach was used initially at Kabul-area hospitals and then expanded into the provinces.  At that time, 80 master trainers and 3,000 health workers had been trained by the Public Nutrition Department within Ministry of Public Health.

Reference:

  1. Emily Levitt, K. K., Luc Laviolette, and Nkosinathi Mbuya. (2011). Malnutrition in Afghanistan: Scale, Scope, Causes, and Potential Response. Washington, D.C.: The World Bank.

The Alive and Thrive (A&T) IYCF delivery model in Bangladesh, implemented through BRAC’s Essential Health Care Program, has the four core interventions of the A&T IYCF Community Model:

  • Home visits - community volunteers, community health workers, and IYCF promoters provide mothers of children 0-24 months of age IYCF counseling, coaching, demonstrations, problem-solving, and referrals
  • Antenatal care sessions and postnatal care visits - frontline workers discuss early initiation of breastfeeding and exclusive breastfeeding and provide support for good positioning and attachment
  • Health forums -frontline workers include IYCF messages and issues in small group discussions with pregnant women, mothers, and family members
  • Social mobilization sessions- to raise awareness of IYCF and seek commitments to action by influential members of the community.

35 master trainers were selected from BRAC’s Health Program Training Unit. They were experienced trainers, qualified to train frontline workers, and they received the same curriculum as staff and frontline workers, but the topics were taught in more depth. The training lasted 6 days.

Reference:

  1. Alive and Thrive. (2013). Implementation Manual for BRAC’s Community-based Alive & Thrive Infant and Young Child Feeding Program in Bangladesh.

The New Zealand Breastfeeding Alliance is responsible for offering BFHI train-the-trainer workshops.  New education guidelines for the BFHI in NZ were released in 2008 and these formed the basis for materials in the train-the-trainer education pack and for childbirth education. This resource will be available for anyone working with breastfeeding mothers, incorporating the different levels of involvement, as identified by BFHI requirements.

The train-the-trainer resource includes all materials needed for delivering BFHI education. Participants will develop an understanding of how people learn and what factors need to be taken into account when conducting a BFI training programme. The three- day course explores basic teaching strategies and considers how these can be applied to teaching the core components of the BFI practice. All participants are required to deliver one short presentation as part of the workshop.

An accredited BFI training package is provided to all participants. This includes an outline of clear aims and learning objectives, sample lesson plans, a summary of basic teaching strategies, additional resources and a range of PowerPoint presentations for future use. The programme format is delivered through a series of learning modules to ensure trainers can confidently and effectively use the training package.

The purpose of this 3-day Training of Trainers course is to strengthen the capacity of a team of trainers by applying different training methodologies and principles of adult learning to the trainings of health service personnel and community-based health workers.

Topics:
Concepts and principles of adult learning
Steps to behavior change
Process of planning a training/ learning event 
Types of learning objectives
Effective facilitation skills
Advantages and disadvantages of effective training/learning methodologies
Audio-visuals as a training tool
Elements of a lesson plan
Types of training/learning evaluation
Components of a training/learning action plan

As a pre-requisite to attend this workshop, all participants should ideally have attended a minimum of thirty hours of lactation education, demonstrate clinical breastfeeding competence and have adult educator experience.

References:

  1. Martis, R., & Stufkens, J. (2013).  The New Zealand/aotearoa baby-friendly hospital initiative implementation journey: piki ake te tihi--"strive for excellence". J Hum Lact, 29(2), 140-146. doi:10.1177/0890334413480849
  2. New Zealand Breastfeeding Alliance Health Professionals Education and Training
  3. New Zealand Breastfeeding Alliance BFHI Train the Trainer Brochure.

Coordination and Integration of Breastfeeding Training Programs Theme

In 2010, the Bangladesh Institute of Public Health Nutrition (IPHN) of the MOH developed the National Communication Framework and Plan for IYCF, with support from National Nutrition Services, NICEF, CARE, Alive & Thrive (A&T), BRAC, Save the Children and many other government departments, NGOs and professional organizations. A Nutrition Working Group had been actively working to share information of broader nutrition programs and from this grew the IYCF Alliance- composed of UNICEF, CARE, Save the Children, Alive & Thrive, and various government departments.
The Terms of Reference (TOR) for the IYCF alliance are in Annex 2 of the Bangladeshi WBTi 2015 report.  It states, “The national IYCF Alliance of Bangladesh comprises partners from Government, UN, Development Partners, Agencies, Organizations, Academia, Media, Private Sector and NGOs who wish to strengthen and harmonize programing and communication efforts to accelerate improvements in infant and young child feeding practices.” 

The IYCF Alliance objectives include:

  • To develop and maintain coordination and mapping of activities being supported by different agencies/partners in the country, promoting a more comprehensive and effective program optimal use of resources and avoidance of duplication.
  • To harmonize BCC activities related to IYCF.

The IPHN/National Nutrition Services are the convener organizations and hold secretariat responsibilities.  The Alliance meets quarterly and among other activities, updates the Bangladeshi map showing areas where different stakeholders are working or planning to work on IYCF and shares information on both community and facility-based IYCF programs.   The Government of Bangladesh took responsibility for mapping the location of all these programs and A&T ran a database tracking the number of CHWs and trainers who received training.  The IYCF Alliance ensured a high level of interest in IYCF and strengthened the sustainability of the programs.  The alliance allowed for expansion of the IYCF programme beyond A&T/ BRAC to new implementers, including the tools, skills and successful approaches employed by A&T.          
By 2014, BRAC had integrated IYCF in 140 Essential Health Care sub-districts, slums in 9 cities through the urban MNCH program, and 82 sub-districts through the rural MNCH program.  Existing frontline CHWs received additional training on IYCF to allow them to do demonstrations, counseling, and coaching on complementary feeding during home visits.  BRAC found that there was a lot of interest in child nutrition and this motivated CHWs to want more knowledge and skills to improve feeding practices.

References:

  1. Stein, N. (2015). Public Health Nutrition: Principles and Practice in Community and Global Health: Jones & Bartlett Learning.
  2. Bangladesh Breastfeeding Foundation. (2015). Bangladesh- WBTi Report.
  3. Sanghvi, T., Haque, R., Roy, S., Afsana, K., Seidel, R., Islam, S., . . . Baker, J. (2016). Achieving behaviour change at scale: Alive & Thrive's infant and young child feeding programme in Bangladesh.Maternal & Child Nutrition, 12(S1), 141-154.
  4. BRAC. (2014). Scaling Up and Sustaining Support for Improved Infant and Young Child Feeding: BRAC’s Experience through the Alive & Thrive Initiative in Bangladesh.

In Afghanistan, breastfeeding training is integrated into the wider national public health training program for the Afghan CHWs.  The CHW Manual and curriculum were developed through consensus workshops with the MOH, UNICEF, WHO and other NGOs and the specific focus of this community-based health care system is on child and maternal health.  CHWs collaborate with and support community midwives and promote good nutrition though encouraging early and exclusive breastfeeding for six months.

This manual provides an overview of the roles and responsibilities of CHWs in meeting the health needs of the population, as well as key information and skills the CHWs require. Each chapter includes sections on: background, things to know, things to do and key points. The health topics covered: personal and home hygiene, safe food and water, immunization, nutrition, preventing common infectious diseases, maternal, newborn and child health, family planning, nutrition, HIV/AIDS, TB, first aid and mental health. The training manual also addresses key skills for CHWs, such as basic assessment and diagnosis, referral, communication, community mapping, household surveys, and basic drug administration. The topics are based on the Basic Package of Health Services, the Community Based Health Worker Policy and the National Health Policy of Afghanistan.

The CHW is the primary or first level of health workers of the Afghan Health Care System. Their main task is to promote a healthy community through healthy behaviors and a healthy environment. They also encourage use of the local health facility for preventive health services. They treat common health problems and recognize life threatening problems that need referral.

The CHW serves 100 –150 families within his/her own community. In isolated and remote areas with scattered populations, one CHW will serve 30 – 50 families.

Reference:

  1. General Directorate of Preventive Medicine and Primary Health Care, Community Based Health Care (CBHC), Department Ministry of Public Health. (2005).  Islamic Republic of Afghanistan Ministry of Public Health Community Health Worker Training Manual.

Facility-Based Delivery Theme

The Brazillian Ministry of Health issues the guide, “Ten Steps to a Healthy Diet: Food Guide for Children Under Two Years: A Guide to Professional Health in Primary Care” to every primary health facility in the country. Step 1: “Giving only breast milk until 6 months, with no water, tea or any other food” gives specifics on why and how health professionals can support mothers in exclusive breastfeeding.

Reference:

  1. Ministry of Health, Brazil. (2002). Dez Passos Para Uma Alimentação Saudável (Ten Steps to a Healthy Diet: Food Guide for Children Under Two Years: A Guide to Professional Health in Primary Care).
The New Zealand Breastfeeding Alliance (NZBA) is the national authority for the implementation of the BFHI and Baby-Friendly Community Initiative (BFCI) in New Zealand and is funded by the Ministry of Health. The BFI in New Zealand is based on the WHO/UNICEF global criteria for baby-friendly hospitals, the International Code of Marketing of Breast-milk Substitutes and subsequent World Health Assembly resolutions and it ensures the inclusion of Maori and other ethnic groups. In 2011, documents on the BFI were revised to meet the updated UNICEF/WHO standards. By 2013, nearly all services had achieved accreditation and 99.85% of infants were born in BFI accredited maternity services.

The average rate of exclusive breastfeeding at discharge from baby-friendly facilities increased from 56% in2001 to 83% in 2008; in 2007, 52% of infants were exclusively breastfed at 6 weeks of age (up from 46% in 2002), and 39% of infants were being breastfed at 3 months (up from 33% in 2002).

The NZBA is a broad-based coalition of professional and consumer organizations which provides information, training, support and assessment of maternity facilities and health services working to implement best practice in relation to breastfeeding. The resources available through this site include:

  • all BFHI accredited facilities;
  • an extensive list of resources for promoting BFHI/Ten Steps;
  • BFHI Assessor job description- a useful list of responsibilities, specifications and performance measures for a BFHI assessor in New Zealand (Reference # 2) ;
  • BFHI Documents Part1 - a broad background to national BFHI implementation in New Zealand.  Page 19 and 20 have a useful flowchart of the BFHI assessment process and elaborates further on each step of the assessment, specifically what materials and paperwork will be needed and time frames (Reference # 3); 
  • BFHI Documents Part 2- further details on the levels of training required for BFHI accreditation and how each of the Ten Steps should be implemented, including examples of how different levels of staff training needs can be accommodated efficiently and effectively (Reference # 4);
  • BFHI Documents Part 3a- a BFHI pre-assessment document which acts as an aide-memoire for the actual pre-assessment questionnaire (part B) and includes samples of tables and data collection to illustrate how facilities complete and provide information to the assessment team (Reference # 5);
  • BFHI Documents Part 3b - An example of the BFHI pre-assessment questionnaire (Reference # 6);
  • BFHI Documents Part 5- an example of the annual BFHI survey all New Zealand maternity facilities are required to complete (See Reference # 7); and
  • BFHI pocket cards-   a quick reference guide for health professionals on the goals of BFHI, WHO/UNICEF International Code of Marketing of Breastmilk Substitutes, 10 Steps to Successful breastfeeding and the New Zealand Ministry of Health Breastfeeding Definitions (Reference # 8).

The NZBA selects and trains BFHI trainers and assessors, provides education/training workshops for assessors and maintains the database of accredited assessors, maternity facilities, and education. The BFHI Assessor Training is a two-day workshop designed to ensure a high level of auditing practices are maintained in all baby friendly hospitals. The workshop provides all Assessors with a strong foundation of knowledge covering all BFHI documents for Aotearoa New Zealand, and the audit process, including the skills required to assess a facility's standard of care against the BFHI's standards, and how to interpret and collate interview responses. Participants also have extensive opportunities to practice using the Baby Friendly Assessment Tool (See References # 5 & 6)

In 2001, the Ministry of Health contracted the NZBA to assess 30 maternity facilities (36% of maternity facilities) before BFHI implementation. The audit evaluated each facility's achievement of the 10 steps and provided a baseline assessment both BFHI implementation and breastfeeding data collection.  All maternity facilities are now assessed and reaccredited every three years using the same process as the initial 2001 audit, including interviews with mothers and a review of progress against previous recommendations. The NZBA considers this aspect to be a crucial part their BFHI audit system - lapses in breastfeeding practice can happen in between reaccreditations and this process allows for quick identification and effective responses.  In addition to the three-year re-assessment, maternity facilities must undertake an annual self-audit.

Through this process, the NZBA have identified some key success factors in maintaining BFHI accreditation; facilities with a paid, dedicated BFHI coordinator and a specific mandate to administer the yearly audits, have better records, data collection, and standards.  These coordinators ensure policies are disseminated, run training programs, and review breastfeeding practices.  Additionally, the required annual self-audit has also made a difference, with improved data collection and exclusive breastfeeding rates going up.  The 2001 audit found the average rate on discharge from these facilities for exclusive breastfeeding was 55.6%., in 2011 the rate was 84.4%.

References:

Sri Lanka's Lactation Management Centres are located in every specialist hospital that provides maternity services and newborn care.  They are supervised by the Neonatologist/Pediatrician in charge of the Special Care Baby Units and have a Medical Officer on site but the day to day running is managed by Nursing Officers.  Nurses are required to have either the 40 hour WHO/UNICEF Breastfeeding Counseling Course or 20 hr BFHI Course. These training programmes are run by the Family Health Bureau (FHB).  The service has two nurse available seven days a week from 7 am – 5 pm and there are telephone hotlines.  Any mother with problems breastfeeding may use the center for free, without referral letters or appointments.
In addition to looking after any in-hospital patients, Nursing Officers advise by telephone, attend to out-patients, speak at ante-natal health educational classes, take part in special day/half-day programmes organized to educate nursing officers staff in other wards and run lecture/clinical sessions for nursing students and midwifery students.

Reference:

  1. Wickramasinghe, S. (2012). Lactation management centres: A step forward in successful breast feeding.Sri Lanka Journal of Child Health, 41(2).

The WHO/UNICEF manual, Baby-friendly hospital initiative: revised, updated and expanded for integrated care was revised in 2009 in light of experience with BFHI since the Initiative began, the guidance provided by the new Global Strategy for Infant and Young Child Feeding, and the challenges posed by the HIV pandemic. Section 1, Background and Implementation, provides guidance on the revised processes and expansion options at the country, health facility, and community level, recognizing that the Initiative has expanded.  It includes information about country level and hospital level implementation, the Global Criteria for BFHI, compliance with the International Code of Marketing of Breast-milk Substitutes, Baby-friendly expansion and integration options, and resources, references and websites.  Section 4 covers hospital self-appraisal and monitoring. It provides tools that can be used by managers and staff, to help determine whether their facilities are ready to apply for external assessment, and, once their facilities are designated Baby-Friendly, to monitor continued adherence to the Ten Steps. This section includes:

  • Hospital Self-Appraisal Tool -
    • Guidelines and Tool for Monitoring
    • The Hospital Self-Appraisal Tool
    • Using the hospital self-appraisal tool to assess policies and practices
    • Analysing the self-appraisal results
    • Preparing for external assessment
    • The self-appraisal questionnaire
    • Annex 1: Hospital breastfeeding/infant feeding policy checklist
    • Annex 2: The International Code of Marketing of Breast-milk Substitutes
    • Annex 3: HIV and infant feeding recommendations
    • Annex 4: Acceptable medical reasons for use of breast-milk substitutes
  • Guidelines and Tools for Monitoring Baby-Friendly Hospitals-
    • Guide to developing a national process for BFHI monitoring
    • Background
    • Rationale for monitoring and reassessment
    • Strategies for monitoring
    • Integrating BFHI monitoring into quality assurance or accreditation programs
    • Sample tools for monitoring
    • Annex 1: Infant feeding record and report
    • Annex 2: Staff training record and report
    • Annex 3: BFHI monitoring tool
    • Annex 4: The BFHI reassessment tool and its possible use for monitoring

The Academy of Breastfeeding Medicine Model Hospital Policy was developed to promote maternal infant care that advocates and supports breastfeeding.  It is based on recommendations from the Office on Women’s Health of the U.S. Department of Health and Human Services, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the World Health Organization, the American Dietetic Association, the Academy of Breastfeeding Medicine, and the UNICEF/WHO evidence-based Ten Steps to Successful Breastfeeding. The protocol serves as a guideline for hospitals to write and implement policies for the care of breastfeeding mothers and infants.

References:

  1. World Health Organization, UNICEF. (2009).  Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care.
  2. World Health Organization, UNICEF. (2009).  Baby-Friendly Hospital Initiative: Section 4-Hospital Self-Appraisal and Monitoring.
  3. Academy of Breastfeeding Medicine Protocol Committee. (2007).  ABM Clinical protocol# 7: Model breastfeeding policy.

Community-Based (i.e. Non-Health Care Facilities Delivery) Theme

The Alive & Thrive (A&T) team in Bangladesh designed a community-based model for improving IYCF practices with four core interventions undertaken by the cadre of BRAC community health workers (CHWSs): 

  • Home visits to mothers of children under 2 years by a trained CHW and IYCF promoter -  provide IYCF counseling, coaching, demonstration, problem-solving, and referrals; 
  • Antenatal care sessions and postnatal care visits by CHWs  - encourage early initiation of breastfeeding and exclusive breastfeeding and provide support for good positioning and attachment;
  • Health forums by CHWs – discussions on IYCF issues;
  • Community mobilization sessions - to raise awareness of optimal IYCF practices and encourage the support of influential community members, such as religious leaders (imams), informal health care providers (village doctors), traditional birth attendants, government health and family welfare staff, school teachers from private secondary and religious schools, adolescent girls, members of village health committees, and fathers.

Prior to rolling out these community-based outreach programs, BRAC and A&T reviewed existing materials, developed training and community mobilization modules and a pocket-size brochure for CHWs.   IYCF Program organizers were in charge of overseeing the programs at field level and for mapping households with children under 2 years of age.  This activity allowed for managers to reassign households in order to even out workloads. Training of master trainers followed by training of frontline workers, supervisors, and program staff was undertaken. 

Where issues with retention of CHW staff arose, BRAC hired new recruits that received three-day training in IYCF so they could immediately begin to counsel and coach.  Later, they received 15 additional days of training and took on the full responsibilities of a CHW in the Essential Health Care Program.   

Monitoring data found that during a 3-month period, 92 percent of mothers had been counseled on IYCF practices.  The differences between the A&T program areas (with the full level of community interventions) and other areas was the presence of CHWs with more extensive training in IYCF, community mobilization activities for community groups and performance-based cash incentives (for CHWs) linked to feeding practices. The gains were much larger in these areas.

Table 1 in Reference #1 sets out the community-based IYCF Interventions employed in Bangladesh, including the specific program details within the A&T areas, other BRAC districts and the rural MNCH areas.

Reference:

  1. BRAC. (2014).  Scaling Up and Sustaining Support for Improved Infant and Young Child Feeding: BRAC’s Experience through the Alive & Thrive Initiative in Bangladesh.

Text4baby is a free mobile information service of the National Healthy Mothers Healthy Babies Coalition and it provides timely health information to women across the country, from early pregnancy throughout their baby’s first year. The service sends important educational messages that are timed to the mother’s stage of pregnancy or to the baby’s age. Topics include nutrition, seasonal flu prevention and treatment, mental health, risks of tobacco use, and breastfeeding. The texts do not carry any charges and do not count towards monthly minimums. http://www.text4baby.org/

Interest in mobile health (mHealth) was driven by the need to improve health literacy about maternal and child health within African-American and Hispanic American populations and those within lower income households. African-American and Hispanic American women typically send more text messages than their white counterparts. Those near the poverty line are more likely to live in cell phone-only households (no fixed phone line), and research shows that those living in cell phone-only households are more likely to have experienced barriers to health care.

Text4baby is a public-private partnership, involving government bodies, non-profits and health-care companies.   Promotion at the grassroots, state, and national levels produced rapid uptake across the United States. More than 320,000 people enrolled with text4baby between February 2010 and March 2012. A critical part of the venture was the agreement by 18 wireless carriers to absorb messaging costs so that text4baby could be provided free of charge. 

The strengths of this initiative are the use of a popular and familiar technology and the involvement of the National Healthy Mothers Healthy Babies Coalition with the Centers for Disease Control and Prevention (CDC) and other federal partners. They ensured the messages were evidence-based and in harmony with national guidelines. The messages were reviewed by an interdisciplinary panel of experts including nurses, obstetricians, nurse-midwives, pediatricians, medical epidemiologists, mental health professionals, nutritionists, lactation consultants and a clinical geneticist and then tested with the target audience and revised according to feedback. Each text message delivers just one action point and participants receive no more than three messages per week.

Text4baby has a data analysis toolkit as part of the initiative.  Staff routinely monitor a wide array of data collected by the program to inform and improve promotional, outreach and product strategies. They make data-driven decisions to guide and target text4baby outreach efforts effectively and efficiently. All the project partners receive the data and training to support them in identifying efforts that drive enrollment in their own communities. The toolkit (Reference #4) is designed as a resource to utilize and analyze data from the text4baby portal. It is organized by questions that outreach partners may have, which can be answered using the data available in the portal. In each section there is a brief overview of how to answer each question using text4baby data and also link to additional resources, including webinars and step-by-step guides located in the appendix. The toolkit also includes a section on additional ideas for evaluating text4baby in individual communities.

Research studies on the use of text messages to help facilitate healthy behavior choices show the efficacy of this method in both health promotion and management.  The benefits to text messaging are a fast, low-cost and popular mode of communication. (Cole-Lewis & Kershaw, 2010) Countries may want to consider this method of communication as part of community outreach for both pre- and post-natal interventions.

In 2014, the Text4baby app was launched which provides an additional way for participants to access key information beyond the character limit of text messages. As a complementary tool to the SMS service, the free app offers additional content and interactive features that enhance the overall Text4baby experience. The app is free and can be downloaded from Google Play or ITunes.

App Features:

  • A weekly planning list of medical, developmental and lifestyle calendar items.
  • Polls that allow participants to see how other moms respond to topics like pregnancy symptoms, infant development and emotional experiences.
  • Appointment reminders scheduled via the app that will be sent through the text message service.
  • Helpful health hotlines and community resources.

References:

  1. Jordan, E. T., Ray, E. M., Johnson, P., & Evans, W. D. (2011). Text4Baby.Nursing for Women's Health, 15(3), 206-212. doi:10.1111/j.1751-486X.2011.01635.x.
  2. Whittaker, R., Matoff-Stepp, S., Meehan, J., Kendrick, J., Jordan, E., Stange, P., . . . Johnson, P. (2012). Text4baby: development and implementation of a national text messaging health information service.American Journal of Public Health, 102(12), 2207-2213.
  3. https://partners.text4baby.org/index.php/get-involved-pg/partners/54-get-involved/partners/468-text4baby-launches-app
  4. https://partners.text4baby.org/templates/beez_20/images/HMHB/text4baby_data_analysis_toolkit_final.pdf
  5. Cole-Lewis, H., & Kershaw, T. (2010). Text messaging as a tool for behavior change in disease prevention and management. Epidemiologic reviews, 32(1), 56-69.

The LINKAGES Project was a 10-year (1996-2006) global effort funded by the United States Agency for International Development (USAID), managed by the Academy for Educational Development, whose goal a large scale, community based behavioral change project, aimed at mothers with young infants in resource-poor areas. It reached one million people in Bolivia, 3.5 million in Ghana, and 6 million in Madagascar.  The purpose was to increase timely initiation of breastfeeding and the rate of exclusive breastfeeding through BCC, training, and community activities using the existing network of CHWs. The project sought to integrate breastfeeding in broader nutrition, child survival, and reproductive health programs as well as in relevant non-health programs.

The four core components of the project:

Partnerships – brought groups of nutrition stakeholders together to harmonize nutrition messages and field approaches, develop materials, co-facilitate training sessions, and monitor and evaluate activities.

Capacity building – Practice-based training materials developed for local health workers and community members covering negotiation skills to help mothers change their infant-feeding behaviors. Participants engaged in discussions of key messages, role-plays, demonstrations, and practice in the use of materials such as counseling cards, child health booklets, cloth flipcharts, and posters. Training undertaken to saturation levels in communities to deal with staff retention issues - in Madagascar, 2,000 health workers, 700 NGO staff, 250 community trainers, 12,000 community health volunteers, and 4,300 members of women’s groups were trained.

Behavior change communication (BCC) - interventions were built on formative research and sustained through program activities that focused on bringing about the desired behavior change. Specific, simple actions to be taken, such as “put the baby to the breast within the first hour after birth” rather than those on the general benefits of breastfeed, were promoted through targeted messages.  These small do-able actions were identified during the formative research phase. These were communicated through interpersonal communication (health worker to mother, community worker to mother, mother to mother), group activities and community mobilization, and mass media (radio, television, and print). In Bolivia, a nationwide radio campaign, with the same messages promoted by community health workers, included 6 radio spots,4 radio dramas, and 5 songs in 3 languages (Spanish, Aymara, and Quechua). The campaign was implemented periodically over 2 years.

Community activities - to reach mothers individually or in groups.  These were a mix of small- and large-group activities, one-on-one counseling in homes and at local health posts, breastfeeding promotion songs performed by women’s groups and musical troupes, and community mobilization events such as local theater, health fairs, and festivals celebrating breastfeeding and child health days, healthy baby contests, and nutrition certificates for families with optimally fed babies.

The program results show that community based BCC interventions led to significant increases in timely initiation of breastfeeding and exclusive breastfeeding over large populations. In Ghana and Madagascar, these increases were seen as rapidly as 9 to 12 months after the start of the community activities.

Some lessons learned from these projects include:

  • Think ‘big’, develop a shared vision of scale with stakeholders, and make the commitment to scale at the very start of the assessment phase.
  • The most successful scaling up strategy is likely to be one that employs various approaches, is situational and ‘opportunistic’, and is based on assessment of the readiness, potential, and reach of partners.
  • During the planning and assessment phase, use a team approach and engage multi-level stakeholders - cultivate a blending of ideas, opinions, and perspectives.
  • Sensitize key in-country players from the national level to the local community leaders to your ideas, through a marketing approach and using various tools and approaches.
  • Identify enough local partners to gain adequate geographic coverage;
  • Ensure adequate program staffing to support the scale of intervention activities, including resources available from partners.
  • Identify a set of small, doable actions.
  • Support a mix of activities at the same time for a comprehensive approach combining short-term and longer-term interventions.
  • Saturate the catchment population with repeated messages from multiple sources for a positive effect on behavior.
  • Compromise and be flexible in program roll-out, allowing for innovation and adaptation to the local situation.

References:

  1. Quinn, V. J., Guyon, A. B., Schubert, J. W., Stone-Jimenez, M., Hainsworth, M. D., & Martin, L. H. (2005). Improving breastfeeding practices on a broad scale at the community level: success stories from Africa and Latin America.J Hum Lact, 21(3), 345-354. doi:10.1177/0890334405278383
  2. Baker, E. J., Sanei, L. C., & Franklin, N. (2006). Early initiation of and exclusive breastfeeding in large-scale community-based programmes in Bolivia and Madagascar.J Health Popul Nutr, 24(4), 530-539.

The Public Health Midwife (PHM) is the “front line” health worker providing domiciliary care to women of reproductive age and children within the community, across the country. 91.4% of new mothers receive at least one post-natal home visit. Each PHM has a well demarcated geographic area with a population ranging from 3000 to 5000 and maintains a register for all eligible females (eligible couple’s register) in the reproductive age and families with children less than 5 years.  This enables the PHMs to provide a continuum of care commencing before pregnancy. Through systematic home visits, they provide domiciliary services to pregnant women, post-partum women, newborns and children under five and clinic services and community level health activities such as group health awareness and promotion. The PHM is a member of the health team providing MCH services at field and institutional clinics and links the domiciliary services at community level with clinic and institutional care.  
PHMs carry out the following postnatal home visits and clinic visit schedule:   

  • 2 home visits during first 10 days after delivery (first visit as soon as mother reached home – within 5 days) 
  • 1 home visit during 14-21 days after delivery     
  • Postnatal clinic visit 4-5 weeks after delivery  
  • 1 visit around 42 days (6-7 weeks) after delivery

References:

  1. Family Health Bureau, Ministry of Health, Sri Lanka. (2011). National Strategic Plan: Maternal and Newborn Health (2012-2016).
  2. Chandradasa, L., & Rowel, D. (2014). National Programme to Protect, Promote, and Support Breastfeeding in Sri Lanka. Paper presented at the Experience with Protection of Breastfeeding in SUN countries in Asia, Webinar.

Supervision Theme

The United States Lactation Consultant Association (USLA) created a guidance note providing FTE (Full Time Equivalent) staffing recommendations for lactation consultants in various hospital settings. (Reference #1) These calculations may be used in conjunction with Staffing for Hospital Lactation Programs: Recommendations From a Tertiary Care Teaching Hospital by Rebecca Mannel, BS, IBCLC, and Robert S. Mannel, MD. (Reference #2) The difference between the two methodologies is that the Mannel paper uses breastfeeding rates and the USLCA do not, primarily because one of the purposes of a lactation consultant is to increase those rates.

References:

  1. United States Lactation Consultant Association. (2010).International Board Certified Lactation Consultant Staffing Recommendations for Inpatient Setting.
  2. Mannel, R., & Mannel, R. S. (2006). Staffing for hospital lactation programs: recommendations from a tertiary care teaching hospital.Journal of Human Lactation, 22(4), 409-417.
Breastfeeding support, Raichur, India

A technology enhanced campaign uses laptops to support breastfeeding among women in a rural area in Raichur, India. © 2013 Dr Abhay Mane/ Smt. Kashibai Navale Medical College, Courtesy of Photoshare