Improving hospital care for breastfeeding support in Indonesia PI: Francisca Handy Agung, Center for Health Research, Universitas Indonesia USG-Supported Partner: Valerie Flaherman, University of California, San Francisco School of Medicine Project dates: February 2015 - June 2019 Project Overview: Breastfeeding, especially exclusive breastfeeding, is one of the most effective preventive health measures available to reduce infant morbidity and mortality. For all newborns, but especially for the sick ones, breastfeeding is a simple life saving method. To improve worldwide breastfeeding initiation and duration rates, the WHO and UNICEF launched the Baby-Friendly Hospital Initiative (BFHI) in 1991. The BFHI consists of the Ten Steps to Successful Breastfeeding and the WHO International Code of Marketing of Breast-milk Substitutes. The BFHI is currently the gold standard for evidence-based breastfeeding care in hospitals. Data continues to accumulate showing that adherence to the Ten Steps predict breastfeeding duration and exclusivity long after hospital discharge. However, despite the strong evidence for the Ten Steps, hospital compliance in Indonesia is poor. A national survey for hospitals in Indonesia in 2011 found only 8% of state hospital complying with 7 out of 10 steps of successful breastfeeding. In order to improve hospital care for breastfeeding we need to identify the barriers and opportunities of BFHI Implementation in Indonesia and obtain solid local evidence on implementing of BFHI by performing a pilot project. Thus, this project will consist of 2 studies. Study 1 is a qualitative study exploring the barriers and facilitators of BFHI implementation in Indonesia. This study will cover various stakeholders related to hospital support for breastfeeding in Indonesia from all levels: Ministry of Health, Provincial and district health offices, related professional organization, several selected hospitals, and community mother support groups. Three provinces that will be involved are Jakarta, West Java, and Banten. One district will be selected for each province and three hospitals will be selected in the respective district. Study 2 is a quasi-experimental study which will be conducted in Banten Province involving 6 hospitals with different types of services and ownership that will be randomly allocated to intervention and control groups - 3 hospitals for each group. The intervention is WHO BFHI section 2 (training for hospital managers), WHO BFHI section 3 (training for maternity staff), and 12 months technical assistance performed by Indonesian Breastfeeding Center. The outcomes of this study are the performance of hospitals on BFHI implementation using WHO module, breastfeeding self efficacy scale, family breastfeeding support scale, LATCH score, and breastfeeding rates. These outcomes will be measured both for healthy and sick newborn. Summary of Recent Activities:  The project was completed in June 2019. From the phase 1 study, 5 themes were identified as contributing to low rates of early exclusive breastfeeding in Indonesian hospitals: 1) quality and quantity of breastfeeding education; 2) marketing and influence of infant formula manufacturers; 3) hospital infrastructure; 4) policy, legislation and protocols; and 5) perceived need for infant formula supplementation. Participants noted that providers and mothers receive inadequate or incorrect education regarding breastfeeding; manufacturers promote infant formula use both inside and outside hospitals; constraints in physical space and hospital design interfere with early breastfeeding; legislation and protocols designed to promote breastfeeding are inconsistently enforced and implemented; and providers and mothers often believe infant formula is necessary to promote infant health. All participants identified numerous barriers to early exclusive breastfeeding that related to more than one identified theme. Following the phase 1 study, the phase 2 study has found that the Indonesian version of WHO-BFHI module training with supportive supervision as the most beneficial intervention compare to training only and control group. Step 7 (rooming in) has been the most improved practice that increase the breastfeeding rate at discharged and step 10 is the most difficult step among others to be implemented. One of the hospital in the full intervention group is a big public hospital serving 3 districts with around 400 birth each month with high enthusiasm during the whole process and this hospital has been the best performance compare to other. It has been successfully increased the breastfeeding rate from 2% up to 98%. Following this, as mentioned previously this hospital has been selected by the Provincial Health Offices to serve as an example to other hospital to develop a baby friendly service. PEER Health Cycle 2 Recipients