New Zealand’s Train the Trainers

The New Zealand Breastfeeding Alliance (NZBA) is responsible for offering Baby-Friendly Hospital Initiative(BFHI) and Baby-Friendly Community Initiative (BFCI) Train-the-Trainer three-day workshops. Only experienced individuals are certified to become BFHI/BFCI educators in their community. BFHI accreditation of maternity facilities has risen in New Zealand from 0% in 2000 to 96.1% in 2011, in part because of this national training program. This increase in BFHI/BFCI accreditation as well as health worker education has helped accelerate exclusive breastfeeding rates at discharge from 55.6% in 2001 to 84.4% in 2011.

Description & Context

The New Zealand Breastfeeding Alliance (NZBA), established in 1998, is the national authority for the implementation and management of the Baby Friendly Hospital Initiative (BFHI) and Baby-Friendly Community Initiative (BFCI) (1). After an initial self-appraisal using NZBA’s online WHO/UNICEF BFHI resources, maternity facilities can request a BFHI assessment (2). NZBA then carries out the BFHI assessment using WHO/UNICEF standardized documents and reassesses facilities every three to four years to approve reaccreditation (3). In addition to the three-year reassessment, maternity facilities must undertake an annual self-audit.

To kick start improvement in breastfeeding rates and practices in maternity facilities after the establishment of the NZBA, New Zealand launched the Baby Friendly Initiative (BFI) in 2000 (4). In 2001, the NZBA under contract from the Ministry of Health audited 30 maternity facilities for their compliance to the “Ten Steps to Successful Breastfeeding,” the International Code of Marketing of Breast-milk Substitutes, and their breastfeeding rates (4). Since then, BFHI accreditation of maternity facilities has increased from 0% in 2000 to 96.1% in 2011 (6). Exclusive breastfeeding rates at discharge from maternity facilities also rose from 55.6% in 2001 to 84.4% in 2011 (6). Through this process, the NZBA have identified some key success factors in maintaining BFHI accreditation such as 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.

Main Components

NZBA is a coalition of representatives from 30 breastfeeding stakeholder organizations contracted and funded by the Ministry of Health to (3):

• Implement and administer the Baby Friendly Hospital Initiative (BFHI) and the Baby Friendly Community Initiative (BFCI) in accordance with the WHO/UNICEF global criteria
• Conduct assessments and reassessments for BFHI and BFCI
• Work to improve breastfeeding rates for the Maori
• Develop materials and resources to support the Baby Friendly Initiative

The NZBA has extensive BFHI resources available online including (8):

• A list of all BFHI accredited facilities
• An extensive list of resources for promoting BFHI/Ten Steps
• The BFHI Assessor job description: a useful list of responsibilities, specifications and performance measures for a BFHI assessor in New Zealand (9)
• BFHI Documents Part 1: a broad background to national BFHI implementation in New Zealand, including a useful flowchart of the BFHI assessment process and elaboration on each step of the assessment, specifically what materials and paperwork will be needed in what time frames (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. This document includes examples of how different levels of staff training needs can be accommodated efficiently and effectively (5)
• 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 (7)
• BFHI Documents Part 3b: An example of the BFHI pre-assessment questionnaire (2)
• BFHI Documents Part 5: an example of the annual BFHI survey all New Zealand maternity facilities are required to complete (10)
• BFHI pocket cards: a quick reference guide for health professionals on the goals of BFHI, the WHO/UNICEF International Code of Marketing of Breast-Milk Substitutes, 10 Steps to Successful Breastfeeding, and the New Zealand Ministry of Health Breastfeeding Definitions (11).

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 (6). 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 (2, 7, 8).

To become a Baby Friendly Hospital, the maternity facility must first perform an initial self-appraisal that includes the collection of infant feeding data, and an assessment of the hospital policy, training, and environment (2). This self-appraisal document is available online from NZBA’s website and is certified by WHO/UNICEF (2). From this self-appraisal, the facility must develop an action plan in consultation with the NZBA and implement the necessary changes in the areas identified. They then apply to NZBA for a BFHI assessment (7). After being approved as Baby Friendly, the maternity facility monitors practice and works to maintain standards evidenced through the BFHI Annual Survey (3). After 3-4 years, reaccreditation/reassessment is required and carried out by NZBA (3). Should the facility not pass reaccreditation, they work with the NZBA to analyze and fix the problems (3).

Evidence of Implementation Strategy

After the NZBA was established in 1998 and the BFI launched in 2000, BFHI accreditation of maternity facilities rose from 0% in 2000 to 96.1% in 2011 (6). Exclusive breastfeeding rates at discharge from maternity facilitates increased from 55.6% in 2001 to 84.4% in 2011 (6), exclusive breastfeeding rates at 3 months of age rose from 30.4% in 2000 to 42% in 2011, and breastfeeding rates at 6 months of age rose from 7.4% to 16% (6).

A 2007 study of the implementation of BFHI in New Zealand public hospitals cites barriers, including variations in policy adoption, circulation, and communication among hospitals, as well as its compliance to government policy. In addition, factors outside of hospital control, such as high-risk referrals, impacted their ability to achieve exclusive breastfeeding rates, and organizational characteristics of hospitals also lead to inadequate dissemination. However, the 2007 study also cited smaller hospital size, a stable workforce, the presence of breastfeeding advocacy groups, and full training of staff with management support to be benefits (15).

Cost and Cost-Effectiveness

Maternity services are publicly funded through the Ministry of Health (MoH), who mandate BFHI accreditation as a requirement (6). In the 2009-2010 fiscal year, the government’s direct funding through the MoH was 72.5% of the country’s total health expenditure at $14,404 million dollars (14). This represents a 119% increase from 2000 (14). $166,200 of the 2009-2010 budget went to education and training of health personnel (14). $54 million went to strategy, policy, and systems performance while $19.9 million went to performance management (14).

Perceptions and Experiences of Interested People

The WHO published an article in 2014 praising New Zealand for its success in increasing breastfeeding rates, citing the success is largely due to the country’s efforts to ensure Baby Friendly-accredited maternity facilities (12). They quote Julie Stufkens, executive officer of the NZBA, as stating that the BFI initiative in 2000 had a large impact on maternity services: adequately trained staff now favor breast milk over formula and are able to give breastfeeding advice and support to mothers in line with the WHO/UNICEF Baby Friendly standards (12).

Case studies from the NZBA website include a BFHI Coordinators Update presentation with expectations, clarification of definitions, and feedback (13). There are also presentations of breastfeeding statistics and breastfeeding among ethnic groups such as the Maori. The NZBA assessment and certification of Baby Friendly hospitals is regularly evaluated, indicating a healthy and functional national program.

A study from a New Zealand university reflects that while maternity staff may at first resist change, as their practices and ideas may be challenged, they have come around to the new policies as they have the goal of improving breastfeeding rates (16).

Benefits and Potential Damages and Risks

• There is a risk that assessing and certifying maternity facilities could favor populations that have access to these facilities. For example, in New Zealand, the NZBA has noted that the Maori have significantly lower breastfeeding rates than New Zealand mothers from European descent (13).
• It is essential that the assessment/certification body use the WHO/UNICEF documents and standards regarding BFHI, the “Ten Steps,” and any other international decree, as these standards represent optimal breastfeeding practices and how to achieve them. Without these guiding documents and standards, improper practices could be promoted, ultimately harming breastfeeding and the health of mothers and infants.

Scaling Up Considerations

• The cost of a national assessment/reassessment/certification program could be significant as it requires training, personnel, and efforts by the maternity facilities. If maternity coverage is included in the MoH budget, as in New Zealand, costs should be covered by the government and a budget line allocated by the MoH.
• It is essential that the assessment/certification body use the WHO/UNICEF documents and standards regarding BFHI, the “Ten Steps,” and any other international decree, as these standards represent optimal breastfeeding practices and how to achieve them.
• A research journal reports that while the program has been successful in urban maternity facilities in improving breastfeeding rates, community maternity services lag behind (6). New Zealand’s next step is to achieve Baby Friendly Community Initiative accreditation for community providers (6). Countries can focus on and perhaps begin with accreditation of urban maternity facilities that reach a large population, and then expand to smaller communities. In addition, breastfeeding support can move from the hospital to the community by referring mothers to breastfeeding support groups in the community (16).
• A 2007 study of the implementation of BFHI in New Zealand public hospitals found that ideal BFHI implementation was in smaller hospitals with a stable workforce, the presence of breastfeeding advocacy groups, and full training of staff with management support (15).

Barriers to Implement

• A 2007 study of the implementation of BFHI in New Zealand public hospitals cites barriers, including variations in policy adoption, circulation, and communication among hospitals, as well as its compliance to government policy. In addition, factors outside of hospital control, such as high-risk referrals, impacted their ability to achieve exclusive breastfeeding rates, and organizational characteristics of hospitals may also have led to inadequate dissemination of BFHI in the hospital (15).
• The cost of a national assessment/reassessment/certification program could be potentially substantial as it requires training, personnel, and efforts by the maternity facilities.
• Accreditation must be undertaken by an organization knowledgeable of the BFHI, Ten Steps, and other international decrees and breastfeeding standards. Not having this source could be a barrier to the program and outside personnel may be necessary to train and educate local actors to properly implement BFHI.

Equity Considerations

The NZBA has noted that the Maori have significantly lower breastfeeding rates than New Zealand mothers from European descent. This may be due to adverse environmental factors, social economic deprivations, and suboptimal breastfeeding support (13). Ultimately, national programs that aim to increase breastfeeding through assessing and certifying maternity facilities need to ensure that these facilities are accessed by all in order to not favor one population. If not possible, other sources of outreach must be utilized to reach these populations that do not access the maternity facilities.

References:

1. New Zealand Breastfeeding Alliance. (2017). About Us. Retrieved from https://www.babyfriendly.org.nz/about-us/new-zealand-breastfeeding-alliance/

2. New Zealand Breastfeeding Alliance. (2014). Baby Friendly Hospital Initiative: Part Three B- Pre-Assessment Questionnaire. Retrieved from http://www.babyfriendly.org.nz/fileadmin/documents/BFHI-document-part3b-primary.pdf

3. New Zealand Breastfeeding Alliance. (2014). Baby Friendly Hospital Initiative: Part One - Background and Baby Friendly Implementation in New Zealand. Retrieved from http://www.babyfriendly.org.nz/fileadmin/documents/BFHI-document-part1.pdf

4. World Health Organization. (2013). Global Nutrition Policy Review: What does it take to scale up nutrition action? Retrieved from http://apps.who.int/iris/bitstream/10665/84408/1/9789241505529_eng.pdf

5. New Zealand Breastfeeding Alliance. (2014). Baby Friendly Hospital Initiative: Part Two - The New Zealand Criteria. Retrieved from http://www.babyfriendly.org.nz/fileadmin/documents/BFHI-document-part2.pdf

6. 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. Retrieved from http://journals.sagepub.com/doi/pdf/10.1177/0890334413480849

7. New Zealand Breastfeeding Alliance. (2014). Baby Friendly Hospital Initiative: Part Three a - Pre-Assessment Questionnaire. Retrieved from http://www.babyfriendly.org.nz/fileadmin/documents/BFHI-document-part3a.pdf

8. New Zealand Breastfeeding Alliance. (2017). https://www.babyfriendly.org.nz/

9. New Zealand Breastfeeding Alliance. (2014). Job Description: Assessor. Retrieved from http://www.babyfriendly.org.nz/fileadmin/documents/Assessor-Job-Description.pdf

10. New Zealand Breastfeeding Alliance. (2014). Baby Friendly Hospital Initiative: Part Five - BFHI Annual Survey for a Primary Facility. Retrieved from http://www.babyfriendly.org.nz/fileadmin/documents/BFHI-document-part5-primary.pdf

11. New Zealand Breastfeeding Alliance. BFHI pocket cards. Retrieved from http://www.babyfriendly.org.nz/fileadmin/documents/BFHIpocketcard.pdf

12. World Health Organization. (2014). “Baby Friendly Hospitals Boost Breastfeeding in New Zealand.” Retrieved from http://www.who.int/features/2014/new-zealand-breastfeeding/en/

13. New Zealand Breastfeeding Alliance (2017). Case Studies. Retrieved from https://www.babyfriendly.org.nz/going-baby-friendly/baby-friendly-hospital-initiative-bfhi/case-studies/

14. Ministry of Health. (2012). Health Expenditure Trends in New Zealand: 2000-2010. Retrieved from https://www.health.govt.nz/system/files/documents/publications/health-expenditure-trends-in-new-zealand-2000-2010.pdf

15. Moore, T., Gauld, R., and Williams, S. (2007). Implementing Baby Friendly Hospital Initiative Policy: the Case of New Zealand Public Hospitals. International Breastfeeding Journal, 2(8). Retrieved from https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/1746-4358-2-8

16. Jackson, Christine. (2005). The Baby Friendly Hospital Initiative Implementing the Process in New Zealand. Victoria University of Wellington. Retrieved from http://researcharchive.vuw.ac.nz/xmlui/handle/10063/25