MCH/MoHP-MCFC-UNICEF BFHI Muti-Center Needs Assessment Survey, 2016

BABY FRIENDLY HOSPITAL INITIATIVE MUTICENTER NEEDS ASSESSMENT SURVEY (BFHI-MAS) Breastfeeding Promotion, Protection and Support UNICEF/WHO BABY FRIENDLY HOSPITAL INITIATIVE Revised Updated and Expanded for Integrated Care

General Department of Motherhood & Childhood Care in Ministry of Health & Population Mother Child Friendly Care Association (MCFC) UNICEF, - Office ∭∭∭ COLLABORATING PARTNERS: Health Directorate Faculty of Medicine & Qaluibiya Health Directorate Faculty of Medicine & Sohag Health Directorate Egyptian Medical Women Association (EMWA) with Gharbia MCH/MoHP

EGYPT, 2016

Page 1 MCH/MoHP-MCFC-UNICEF BFHI Muti-Center Needs Assessment Survey, 2016

PREFACE

This research was initially proposed by MCFC to the Department of MCH/MoHP and UNICEF, Cairo office, as an exercise to identify, through mock assessments, the hospitals and health centers that were ready for final assessment for designation as Baby Friendly as MCFC had a team of International Board Certified Lactation consultants some of whom were also designated national assessors. However it was the wish of the officials in MCH/MoH to identify the needs of hospitals and MCH centers to become Baby Friendly health facilities, as a follow-up of the survey conducted in 2008 (MCH- MoH/ELCA/UNICEF, 2010). The survey was inspired by UNICEF/ECO’s support, motivation and facilitation throughout the work. MCFC started off initially with three governorates: Qaluibiya, Alexandria and Sohag then added (only 4 hospitals and affiliated MCH units). We then formed partnerships with the universities in each governorate. We partnered with Benha University Faculty of Medicine in Qaluibiya and Sohag University Faculty of Medicine, community department in , while utilized our own IBCLCs and national BFHI assessors in Alexandria and Gharbia governorates. The Egyptian Medical Woman Association (EMWA) assisted in the survey of health facilities in Gahrbia and Qaluibiya by their experts in Baby Friendly assessments. The central department of MCH/MoH was very supportive in facilitating and participating in the work. They were involved from the very start in the review of the tools and in training and orientation meetings of the investigators. At Health directorate level, the Undersecretary of Health in the governorate and the local MCH director conducted orientations to the directors of the hospitals and district health officers to prepare them for the survey and for expecting the field surveyors and facilitating their work. These meetings also oriented the staff to the Ministerial Decree (36/2014) released for urging all hospitals to become Baby Friendly by implementing the Ten Steps and complying to the International Code of Marketing of Breastmilk substitutes. Later the MCH/MoH directors in each governorate facilitated the field visits and the wrap-up dissemination and planning workshops conducted at the end of the survey. Three wrap-up workshops were conducted in each governorate with the officials of the health directorate in the hospitals and MCH centers in each governorate for disseminating the results of the survey and planning improvement in each facility. Both the public and private sector were represented in the meetings. The officials actively participated in formulating policies, plans for education and training as well strengthening the community component by the MCH centers and developing indicators for monitoring and evaluation. The exercise motivated all the staff and is expected to pave the way for driving the implementation and designation process to scale at governorate and national level. We would like to express our gratitude to all the officials in the various departmental sectors in the Ministry of Health and the clinical and non-clinical staff and mothers who facilitated and supported this work, their contribution, commitment and dedication was the foundation for this work. This work is dedicated to their babies and to the joy and peace breastfeeding will bring to their lives and to the world. MCFC Board of Directors, 2016

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TABLE OF CONTENTS

List of Tables 5 Step 10 83

List of Figures 9 Mother Friendly 91

Executive Summary 13 Compliance to Code 97

Introduction 20 Section II: MCH Survey 103 Status of Baby Friendly criteria Aim of the Study 22 Step 1 103

Methodology 23 Step 2 105

Section I: Hospital Survey 27 Step 3 107

Status of BFHI global 27 Antenatal education in 109 criteria in hospitals: Mother Friendly

Step 1 34 Step 5 111

Step 2 39 Step 6 113

Step 4 45 Conclusions and 115 Recommendations

Step 5 53 References 118

Step 6 63 List of Participants 120

Steps 7,8 & 9 71 Arabic Summary

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LIST OF ABBREVIATIONS

ALX: BFHI: Baby Friendly Hospital Initiative BMS: Breastmilk substitutes C: criteria CME: continued medical education Code: International Code of Marketing of Breastmilk Substitutes C-S: cesarean section delivery DH: District Hospital EBM: expressed Breastmilk EPI: Expanded program of Immunization FHSTS: first hour Skin-to-skin FP: Family Planning GH: General hospital GHB: Gharbia governorate IMCI: Integrated Management of Childhood Illness IMF: Infant milk formula KMC: Kangaroo Mother care MCH: Maternal and Child Health MF: Mother Friendly practices NCU: neonatal care units NVD: normal vaginal delivery Ped. H : Pediatric Hospital PHC: primary health care QAL: Qaluibiya governorate Sg: Sohag governorate STS: Skin to skin UNICEF: United Nation International Children’s Emergency Fund WHO: World Health Organization

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LIST OF TABLES

Table (1) List of hospitals assessed for needs in each governorate. 27 Table (2) List of hospitals in each governorate by exposure to training and date of training in Baby Friendly 20 hour course. 28 Table (3) Total number of deliveries by region over the past year in the targeted hospitals. 29 Table (4) Total number of staff working in the targeted hospitals by category in each 31 governorate. Table (5) Count of mothers and staff interviewed by category in each district of Sohag governorate. 32 Table (6) Count of mothers and staff interviewed by category and district in Qaluibiya governorate. 32 Table (7) Count of mothers and staff interviewed by category in the hospitals and districts in Alexandria governorate. 33 Table (8) Distribution of interviews conducted by category of population and geographic area. 33 Table (9) Distribution of the scores of Baby Friendly criteria for Step (1) according to the adapted BFHI global criteria in the hospitals providing maternity services in Sohag governorate. 34 Table (10) Distribution of the scores of Baby Friendly criteria for Step (1) according to the adapted BFHI global criteria in the hospitals providing maternity services in Qaluibiya governorate in Egypt. 35 Table (11) Distribution of the scores of Baby Friendly criteria for Step (1) according to the adapted BFHI global criteria in the hospitals providing maternity services in Alexandria governorate in Egypt. 35 Table (12) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (1) for the hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt. 36 Table (13) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (1) for hospitals providing maternity and neonatal services in those exposed to training versus those not recently exposed to any training in Baby Friendly. 37 Table (14) Distribution of the scores of Baby Friendly criteria for Step (2) according to the adapted BFHI global criteria in the hospitals providing maternity services in Sohag governorate. 39 Table (15) Distribution of the scores of Baby Friendly criteria for Step (2) according to the adapted BFHI global criteria in the hospitals providing maternity services in Qaluibiya governorate in Egypt. 40 Table (16) Distribution of the scores of Baby Friendly criteria for Step (2) according to the adapted BFHI global criteria in the hospitals providing maternity services in Alexandria governorate in Egypt. 40 Table (17) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (2) for the hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt. 41 Table (18) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (2) for hospitals providing maternity and neonatal services in those exposed to training versus those not recently exposed to any training in Baby Friendly. 42 Table (19) Distribution of the scores of Baby Friendly criteria for Step (4) according to the adapted BFHI global criteria in the hospitals providing maternity services in Sohag governorate. 46

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Table (20) Distribution of the scores of Baby Friendly criteria for Step (4) according to the adapted BFHI global criteria in the hospitals providing maternity services in Qaluibiya governorate in Egypt. 47 Table (21) Distribution of the scores of Baby Friendly criteria for Step (4) according to the adapted BFHI global criteria in the hospitals providing maternity services in Alexandria governorate in Egypt. 48 Table (22) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (4) for the hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt. 49 Table (23) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (4) for the hospitals providing maternity and neonatal services by exposure to training. 50 Table (24) Distribution of the scores of Baby Friendly criteria for Step (5) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Sohag governorate. 54 Table (25) Distribution of the scores of Baby Friendly criteria for Step (5) according to the adapted BFHI global criteria in the hospitals providing maternity services in Qaluibiya governorate in Egypt. 55 Table (26) Distribution of the scores of Baby Friendly criteria for Step (5) according to the adapted BFHI global criteria in the hospitals providing maternity services in Alexandria governorate in Egypt. 57 Table (27) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (5) for the 31 public hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt. 59 Table (28) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (5) for the 31 public hospitals providing maternity and neonatal services by exposure to training in Baby friendly. 61 Table (29) Distribution of the scores of Baby Friendly criteria for Step (6) according to the adapted BFHI global criteria in the hospitals providing maternity services in Sohag governorate. 64 Table (30) Distribution of the scores of Baby Friendly criteria for Step (6) according to the adapted BFHI global criteria in the hospitals providing maternity services in Qaluibiya governorate in Egypt. 65 Table (31) Distribution of the scores of Baby Friendly criteria for Step (6) according to the adapted BFHI global criteria in the hospitals providing maternity services in Alexandria governorate in Egypt. 66 Table (32) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (6) for the 31 public hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt. 67 Table (33) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (6) for the 31 public hospitals providing maternity and neonatal services by exposure to training. 68 Table (34) Distribution of the scores of Baby Friendly criteria for Step (7, 8 and 9) according to the adapted BFHI global criteria in the hospitals providing maternity services in Sohag governorate. 72 Table (35) Distribution of the scores of Baby Friendly criteria for Step (7, 8 and 9) according to the adapted BFHI global criteria in the hospitals providing maternity services in Qaluibiya governorate in Egypt. 74 Table (36) Distribution of the scores of Baby Friendly criteria for Step (7, 8 and 9) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Alexandria governorate in Egypt. 76 Table (37) Comparison of the scores of Baby Friendly criteria for Step (7, 8 and 9) according to the adapted BFHI global criteria in the hospitals providing maternity services in hospitals of Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt. 78

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Table (38) Comparison of the scores of Baby Friendly criteria for Step (7, 8 and 9) according to the adapted BFHI global criteria in the hospitals by exposure to training. 80 Table (39) Distribution of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in the hospitals providing maternity services in Sohag governorate. 83 Table (40) Distribution of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in the hospitals providing maternity services in Qaluibiya governorate in Egypt. 84 Table (41) Distribution of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in the hospitals providing maternity services in Alexandria governorate in Egypt. 85 Table (42) Comparison of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in the hospitals providing maternity services in hospitals of Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt. 86 Table (43) Comparison of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in the hospitals providing maternity services by exposure to training. 87 Table (44) Distribution of the scores of Baby Friendly criteria for Mother Friendly according to the adapted BFHI global criteria in the hospitals providing maternity services in Sohag governorate. 92 Table (45) Distribution of the scores of Baby Friendly criteria for Mother Friendly according to the adapted BFHI global criteria in the hospitals providing maternity services in Qaluibiya governorate in Egypt. 93 Table (46) Distribution of the scores of Baby Friendly criteria for Mother friendly according to the adapted BFHI global criteria in the hospitals providing maternity services in Alexandria governorate in Egypt. 93 Table (47) Comparison of the scores of Baby Friendly criteria for Mother Friendly according to the global criteria adapted BFHI gin the hospitals providing maternity services in hospitals of Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt. 94 Table (48) Comparison of the scores of Baby Friendly criteria for Mother Friendly according to the adapted BFHI global criteria in the hospitals providing maternity services by exposure to training. 95 Table (49) Distribution of the scores of Baby Friendly criteria for the Code according to the adapted BFHI global criteria in the Hospitals providing maternity services in Sohag governorate. 98 Table (50) Distribution of the scores of Baby Friendly criteria for the Code according to the adapted BFHI global criteria in the hospitals providing maternity services in Qaluibiya governorate in Egypt. 99 Table (51) Distribution of the scores of Baby Friendly criteria for the Code according to the adapted BFHI global criteria in the hospitals providing maternity services in Alexandria governorate in Egypt 100 Table (52) Comparison of the scores of Baby Friendly criteria for the Code according to the adapted BFHI global criteria in the hospitals providing maternity services in hospitals of Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt. 101 Table (53) Comparison of the scores of Baby Friendly criteria for Code compliance according to the BFHI global criteria in the hospitals providing maternity and neonatal care by exposure to training. 102 Table (54) Comparison of the status of Baby Friendly (BFHI) global criteria for Step (1) for maternal and child health centers in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt. 103

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Table (55) Comparison of the status of Baby Friendly (BFHI) global criteria for Step 104 (1) for maternal and child health units exposed to training versus those not recently exposed to any training in Baby Friendly. Table (56) Comparison of the status of Baby Friendly (BFHI) global criteria for Step 105 (2) for maternal and child health centers in Alexandria, Gharbia, Qaluibiya and Sohag governorates. Table (57) Comparison of the status of Baby Friendly (BFHI) global criteria for Step 106 (2) for maternal and child health centers by exposure to training. Table (57) Comparison of the status of Baby Friendly (BFHI) global criteria for Step 107 (3) for maternal and child health centers in Alexandria, Gharbia, Qaluibiya and Sohag governorates. Table (58) Comparison of the status of Baby Friendly (BFHI) global criteria for Step 109 (3) for maternal and child health units exposed to training versus those not recently exposed to any training in Baby Friendly.

Table (59) Comparison of antenatal education in Mother Friendly practices in 109 Alexandria, Gharbia, Qaluibiya and Sohag governorates.

Table (60) Comparison of the status of antenatal education in Mother Friendly 110 practices according to the adapted BFHI global criteria in the hospitals providing maternity services in by exposure to training.

Table (61) Comparison of the status of Baby Friendly (BFHI) global criteria for Step 111 (5) for maternal and child health centers in Alexandria, Gharbia, Qaluibiya and Sohag governorates. Table (62) Comparison of the status of Baby Friendly (BFHI) global criteria for Step 112 (5) for maternal and child health units exposed to training versus those not recently exposed to any training in Baby Friendly. Table (63) Comparison of the status of Baby Friendly (BFHI) global criteria for Step 113 (6) for maternal and child health centers in Alexandria, Gharbia, and Sohag governorates. Table (64) Comparison of the status of Baby Friendly (BFHI) global criteria for Step 114 (6) for maternal and child health centers by exposure to training.

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LIST OF FIGURES Figure (1) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step 36 (1) for the Hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt. Figure (2) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step 37 (1) for hospitals providing maternity and neonatal services in those exposed to training versus those not recently exposed to any training in Baby Friendly. Figure (3) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step 41 (2) for the Hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt. Figure (4) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step 42 (2) for hospitals providing maternity and neonatal services in those exposed to training versus those not recently exposed to any training in Baby Friendly. Figure (5) Distribution of the scores of Baby Friendly criteria for Step (4) according 47 to the adapted BFHI global criteria in the Hospitals providing maternity services in Sohag governorate. Figure (6) Distribution of the scores of Baby Friendly criteria for Step (4) according to the adapted BFHI global criteria in the hospitals providing maternity services in Qaluibiya governorate. 47 Figure (7) Distribution of the scores of Baby Friendly criteria for Step (4) according to the adapted BFHI global criteria for hospitals providing maternity and neonatal services in Alexandria governorate in Egypt. 48 Figure (8) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (4) for the Hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt. 49 Figure (9) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (4) for the Hospitals exposed to BFHI training and those not exposed. 50 Figure (10) Distribution of the scores of Baby Friendly criteria for Step (5) for maternity wards (positioning and attachment) according to the adapted BFHI global criteria in Sohag governorate. 54 Figure (11) Distribution of the scores of Baby Friendly criteria for Step (5) for neonatal care units (milk expression) according to the adapted BFHI global criteria in Sohag governorate. 55 Figure (12) Distribution of the scores of Baby Friendly criteria for Step (5) for maternity wards (positioning and attachment) according to the adapted BFHI global criteria in Qaluibiya governorate. 56 Figure (13) Distribution of the scores of Baby Friendly criteria for Step (5) for neonatal care units (milk expression) according to the adapted BFHI global criteria in Qaluibiya governorate. 56 Figure (14) Distribution of the scores of Baby Friendly criteria for Step (5) according to the adapted BFHI global criteria in the Hospitals for maternity services in Alexandria governorate in Egypt. 58 Figure (15) Distribution of the scores of Baby Friendly criteria for Step (5) according to the adapted BFHI global criteria in the Hospitals for neonatal services in Alexandria governorate in Egypt. 58 Figure (16) Comparison of the scores of Baby Friendly criteria related to interviews with clinical staff on they show mothers how to breastfeed and maintain their supply in the four governorates. 59 Figure (17) Comparison of the scores of Baby Friendly criteria related to interviews with mothers on whether they are supported by staff on how to breastfeed and express their milk to maintain their supply in the four governorates. 60

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Figure (18) Comparison of the scores of Baby Friendly global criteria related to interviews with mothers with babies in special care unit on how they are supported by staff to breastfeed and express their milk to maintain their 60 supply in the 4 governorates. Figure (19) Distribution of the scores of Baby Friendly criteria for Step (6) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Sohag governorate in Egypt. 64 Figure (20) Distribution of the scores of Baby Friendly criteria for Step (6) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Qaluibiya governorate in Egypt 65 Figure (21) Distribution of the scores of Baby Friendly criteria for Step (6) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Alexandria governorate in Egypt. 66 Figure (22) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (6) with regards to policies, registries and protocols (clinical guidelines) for hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates. 67 Figure (23) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (6) as reported by clinical staff and mothers and observed in hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates. 68 Figure (24) Distribution of the scores of Baby Friendly criteria for Step (7) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Sohag governorate. 72 Figure (25) Distribution of the scores of Baby Friendly criteria for Step (8) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Sohag governorate in Egypt. 73 Figure (26) Distribution of the scores of Baby Friendly criteria for Step (9) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Sohag governorate. 73 Figure (27) Distribution of the scores of Baby Friendly criteria for Step (7) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Qaluibiya governorate. 74 Figure (28) Distribution of the scores of Baby Friendly criteria for Step (8) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Qaluibiya governorate. 75 Figure (29) Distribution of the scores of Baby Friendly criteria for Step (9) according to the adapted BFHI global criteria in the hospitals providing maternity services in Qaluibiya governorate. 75 Figure (30) Distribution of the scores of Baby Friendly criteria for Step (7) according to the adapted BFHI global criteria in the hospitals providing maternity and neonatal services in Alexandria governorate in Egypt. 76 Figure (31) Distribution of the scores of Baby Friendly criteria for Step (8) according to the adapted BFHI global criteria in hospitals providing maternity and neonatal services in Alexandria governorate in Egypt. 77 Figure (32) Distribution of the scores of Baby Friendly criteria for Step (9) according to the adapted BFHI global criteria in the hospitals providing maternity and neonatal services in Alexandria governorate in Egypt. 77 Figure (33) Comparison of the scores of Baby Friendly criteria for Step (7) according to the adapted BFHI global criteria in the Hospitals providing maternity services in hospitals of Alexandria, Gharbia, Qaluibiya and Sohag 78 governorates in Egypt. Figure (34) Comparison of the scores of Baby Friendly criteria for Step (8) according to the adapted BFHI global criteria in hospitals providing maternity

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services in hospitals of Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt. 79 Figure (35) Comparison of the scores of Baby Friendly criteria for Step (9) according to the BFHI global criteria in the Hospitals providing maternity services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt 79 Figure (36) Distribution of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in the Hospitals providing maternity services in hospitals of Sohag governorate. 84 Figure (37) Distribution of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in hospitals providing maternity services in Qaluibiya governorate. 85 Figure (38) Distribution of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in the hospitals providing maternity services in Alexandria governorate. 86 Figure (39) Comparison of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in the hospitals providing maternity services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt. 87 Figure (40) Comparison of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in the hospitals providing maternity services by exposure to training. 88 Figure (41) Distribution of the scores of Baby Friendly criteria for becoming Mother Friendly according to the BFHI global criteria in the Hospitals providing maternity services in Sohag governorate. 92 Figure (42) The status of Baby Friendly criteria for Mother Friendly according to the BFHI global criteria in hospitals providing maternity services in Qaluibiya governorate. 93 Figure (43) Distribution of the scores of Baby Friendly criteria for becoming Mother Friendly according to the BFHI global criteria in hospitals providing maternity services in Alexandria. 94 Figure (44) Comparison of the scores of Baby Friendly criteria for Mother Friendly according to the adapted BFHI global criteria in hospitals providing maternity services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt. 95 Figure (45) Comparison of the scores of Baby Friendly criteria for Mother Friendly according to the adapted BFHI global criteria in the hospitals providing maternity services in Alexandria, Gharbia, Qaluibiya and Sohag 96 governorates in Egypt. Figure (46) Distribution of the status of Baby Friendly criteria for Code compliance according to the BFHI global criteria in hospitals providing maternity services in Sohag governorate. 98 Figure (47) Distribution of the scores of Baby Friendly criteria for Code compliance according to the BFHI global criteria in hospitals providing maternity services in Qaluibiya governorate. 99 Figure (48) Comparison of the scores of Baby Friendly criteria for Code compliance according to the BFHI global criteria in the Hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt. 101 Figure (49) Comparison of the scores of Baby Friendly criteria for Code compliance according to the BFHI global criteria in hospitals providing maternity and neonatal care by exposure to training. 102 Figure (50) Comparison of the status of Baby Friendly (BFHI) global criteria for Step (1) for maternal and child health centers in Alexandria, Gharbia, Qaluibiya and Sohag governorates. 103

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Figure (51) Diagrammatic representation of scores achieved for Baby Friendly (BFHI) global criteria for Step (1) by maternal and child health units exposed to training versus those not recently exposed to any training in 104 Baby Friendly. Figure (52) Diagrammatic representation of scores achieved for Baby Friendly (BFHI) global criteria for Step (3) by the maternal and child health centers at governorate level in Alexandria, Gharbia, Qaluibiya and Sohag. 105 Figure (53) Diagrammatic representation of Baby Friendly (BFHI) global criteria for Step (2) for maternal and child health units exposed to training versus those not exposed to training in the Ten steps. 106 Figure (54) Diagrammatic representation of scores achieved for Baby Friendly (BFHI) global criteria of Step (3) by maternal and child health centers in Alexandria, Gharbia, Qaluibiya and Sohag governorates. 107 Figure (55) Diagrammatic representation of scores achieved for Baby Friendly (BFHI) global criteria of Step (3) by maternal and child health centers: trained versus not trained. 108 Figure (56) Comparison of the status of antenatal education in Mother Friendly practices according to the adapted BFHI global criteria by the maternal and child health center staff in the governorates of Alexandria, Gharbia 109 and Sohag. Figure (57) Comparison of the status of antenatal education in Mother Friendly practices according to the adapted BFHI global criteria in the hospitals providing maternity services in by exposure to training. 110 Figure (58) Diagrammatic representation of scores achieved for Baby Friendly (BFHI) global criteria of Step (5) by maternal and child health centers in Alexandria, Gharbia, Qaluibiya and Sohag governorates. 111 Figure (59) Diagrammatic representation of scores achieved for Baby Friendly (BFHI) global criteria of Step (5) by maternal and child health centers in trained versus not trained. 112 Figure (60) Diagrammatic representation of scores achieved for Baby Friendly (BFHI) global criteria: C6.1 to C6.4 of Step (6) by maternal and child health centers in Alexandria, Gharbia, and Sohag governorates. 113 Figure (61) Graphic representation of scores achieved for Baby Friendly (BFHI) global criteria C6.5 to C6.8 of Step (6) by maternal and child health centers in Alexandria, Gharbia, and Sohag governorates. 114 Figure (62) Comparison of status of Baby Friendly (BFHI) global criteria for Step (6) in maternal and child health centers by exposure to training. 114

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EXECUTIVE SUMMARY

This survey was organized by MCFC in collaboration with Benha and Sohag universities under the supervision and auspices of the central MCH/MoH department and supported by UNICEF/ECO. The purpose of the survey was to assess the needs of hospitals and maternal and child health (MCH) centers to become Baby friendly according to the UNICEF/WHO set global criteria in 2009 which was expanded to include the International Code of Marketing of Breastmilk Substitutes (ICMBMS) and mother friendly practices (MF). The survey was conducted in 33 hospitals providing maternity and/or neonatal services and 77 MCH centers in the governorates of Alexandria, Gharbia, Qaluibiya and Sohag using the adapted Baby Friendly Assessment tool of UNICEF/WHO. The survey assessed practices from the private sector in the governorates of Qaluibiya, and Alexandria only, by interviewing a sample of breastfeeding mothers, attending with their babies in the health centers, for their childbirth experiences at a private hospital. The survey was conducted over a period of one month from mid- May to mid-June, 2015. Interviews were carried out for a total of 777 breastfeeding mothers and 443 pregnant women, 781 and 554 medical and nursing staff from hospitals and MCH centers respectively and 260 and 360 support staff from hospitals and MCH centers respectively. Investigators included a team of university staff from the community and family medicine, and pediatrics of Faculty of medicine, Benha University and Cairo University, AlZahraa Faculty of Medicine for Girls, AlAzhar University and Faculty of medicine, Sohag University together with a group of physician certified lactation consultants from Alexandria and . The following are the findings of the status of the Global criteria of the Baby Friendly Hospital Initiative in all the 33 hospitals (including the Ten Steps, Code Compliance and Mother Friendly): Step 1: “Have a written breastfeeding policy” 1- A written breastfeeding or infant feeding policy was present in 11 hospitals (34.375%). 2- The policy covered all the “Ten steps” adequately and the regulatory Code (ICMBMS) implementation measures in only 8 hospitals (25.0%). 3- The policy was displayed in all the areas where mothers and staff are available in 10 hospitals (31.25%) and was displayed in illustrative form in 9 hospitals (28.125%). 4- There was a mechanism for monitoring and evaluation of the policy in 6 hospitals (18.75%).

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Step (2): “Train all health care staff”

1- A written curriculum for training in breastfeeding promotion and support was only available in 6 hospitals (18.18%). 2- All the Ten Steps and the Code were shown to be adequately covered in the training in only 5 hospitals (15.15%). 3- There were training records that indicated that 80% of the target clinical staff had received training of at least 20 hours duration with at least 3 hours of supervised clinical experience in 5 hospitals (15.15%). Overall 29% of the clinical staff interviewed confirmed this, while 45.7% were acquainted with the basic knowledge about breastfeeding support. 4- One third of the nonclinical staff (28.9%) in these hospitals had received an orientation about the policy. Step (3) “Inform pregnant women of the benefits and practice of breastfeeding” was not present in all the hospitals and was assessed in the survey of the MCH health units. Step (4): “Initiate breastfeeding within one hour through skin-to-skin (STS)” 1. One half of the mothers with normal vaginal delivery (NVD) of cesarean (CS) with spinal or epidural anesthesia were given their baby within 5 minutes of birth (53.5%) in public and private hospitals. This improved with training by 25% (from 58.4% to 73.3%) in the public hospitals. 2. In CS with general anesthesia (GA) the baby was given to the mother within 5 minutes of recovery in 21.7%. Fortunately the CS with GA has decreased considerably and is rarely performed being replaced by spinal anesthesia. This is also improved from 21.1% to 50% by training in the public sector. 3. The babies were given to the mother to hold STS for one hour in only 18.4% of cases in NVD or CS with spinal or epidural anesthesia and in 4.3% to mothers delivered CS with GA. Training had no effect on this practice. 4. An attendant with the mother during the STS showed her how to recognize their babies’ readiness to breastfeed in 30.8% of cases. This was not influenced by training in the public sector. 5. Mothers of babies in neonatal care unit (NCU) were encouraged to hold their baby STS in 32.04%. This is improved with training from 37.6% to 58.9% in the public sector. Step 5: “Show mothers how to breastfeed and maintain lactation” 1- The supervisory staff confirmed that their department gives mothers who are at risk adequate help and guidance on how to breastfeed in 51.5% of cases. This improved with training from 51.3% to 71.4%. 2- In rare cases when mothers were unable to breastfeed in 38.7%. These mothers were shown how prepare and feed breastmilk substitutes, through “return demonstration”.

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3- Over two thirds of clinical staff (72.7%) reported that they teach mothers about positioning and attachment and describe correct techniques and 64.7% reported they teach mothers hand expression and give adequate descriptions and demonstrations of what they would teach mothers and can describe the technique it or if they do not teach, describe to whom to refer mothers. The former improved by training from 70.6 to 82% but the latter did not change with training. 4- Only 41.4% of mothers confirmed that staff offered further help with breastfeeding the next time the baby was fed or within 6 hours of delivery but 67.5% were able to demonstrate correct positioning and attachment with their baby, and 25% reported that staff offered further help on how to express milk or gave them a handout on how to do so. These practices improved from 42.5% to 59.5% and 62.5% to 69.6% and from 28% to 34.9% respectively with training. 5- Of the mothers of babies in NCU 24.9% reported that they were guided on how to keep up the supply within 6 hours of their babies’ births (C.10) of the global criteria (C) and 30.7% reported they were shown how to express their milk safely (C.11) and 28.3% were able to demonstrate the correct way of milk expression (C.12). While 32.8% reported they were told they need to breastfeed or express their milk 6 times or more every 24 hours to keep up the supply (C.13). These practices improved with training to 40.7%, 51.7 and 58.3 for the C.10, C.12 and C.13 respectively but not C.11. Step 6: “Give newborns no food or drink other than breastmilk “unless medically indicated”” 1. There were no medical records available for feeding newborns and informal data indicates that at least 75% of the full-term babies delivered in the past year were exclusively breastfed or fed expressed breastmilk by 39.3% of those interviewed. However clinical protocols for breastfeeding and infant feeding management are in line with BFHI evidence-based guidelines in 18.2% of cases only. This improved with training of the public hospitals to 71.4% and 57.2% respectively. 2. There was little promotion and 72.7% confirmed that the materials which recommend feeding breastmilk substitutes, scheduled feeds or other inappropriate practices were not distributed to mothers. This improved with training of the public hospitals to 100%. 3. The hospital had an adequate facility/space and necessary equipment for giving demonstrations on how to prepare formula and other feeding options away from breastfeeding mothers in 63.6%. This improved with training of the public hospitals to 71.4%. 4. Over one half of staff (58.8%) confirmed that if babies were prescribed any substitute it was based on acceptable medical reasons or informed choices for receiving something else and in 39.2% mothers were counseled about

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the hazards of these substitutes. This improved with training of the public hospitals to 90.9% and 100% respectively. 5. Almost two thirds of breastfeeding mothers (68.5%) reported that their babies had received only breastmilk or, if they had received anything else, it was for a justified reason. This improved with training in the public hospitals to 90.5%. 6. 43.3% of mothers of babies in NCUs had been informed of the importance of expressed breastmilk and hazards of supplements other than breastmilk to their babies. This improved with training in the public hospitals to 75%. 7. Health staff reported that they do not prescribe substitutes except for acceptable medical reasons in 85.8%. This improved with training of the public hospitals to 91.3%. 8. Nonclinical staff who advised mothers of the importance of exclusive breastfeeding reported so in 63.9% of cases. This improved with training in the public hospitals to 79.69%. Step 7: “Practice rooming-in” 1- Observations in the postpartum wards, pediatric wards and any well baby observation areas showed that 62.03% of the babies and mothers are rooming-in or, if not, had justifiable reasons for not being together. This improved with training of the public hospitals to 79.8%. 2- 88.92% of mothers reported that their babies had stayed with them since delivery or, if not, there were justifiable reasons. This improved with training in the public hospitals to 92.5%. 3- Mothers in the NCU were encouraged to spend as much time as possible with their babies and to hold their babies STS (giving Kangaroo mother care) in 34.9% of facilities. This improved with training in the public hospitals to 62.07%. 4- Mothers who were working in the facilities were given space to breastfeed their babies or had their babies close to them while at work to continue to breastfeed in 29.03% of health facilities. 5- Mothers who were visiting their babies in the NCU were provided a private space where they could express their milk in 61.3% of health facilities. Step 8: “Encourage breastfeeding on demand” 1- Less than one half of mothers (42.6%) were able to describe at least two things they were told about how to recognize if their babies were hungry. This did not improve with training. 2- Over a third of mothers (39.8%) reported that they had been advised to feed their babies for as often and as long as the babies wanted. This improved with training of the public hospitals to almost two thirds (59.3%). Step 9: “Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.”

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1. Breastfeeding babies observed in any area; were not using bottles and teats 59.6% but if they were, unfortunately their mothers had not been informed of the risks. This improved with training of the public hospitals to 84.5%. 2. 55.7% of breastfeeding mothers reported that their babies were not fed any fluids in bottles with teats while in their birthing facility. This improved with training of the public hospitals to 83.7%. 3. 60.6% of the breastfeeding mothers reported that their babies had not sucked on pacifiers in in their birthing facility. This improved with training of the public hospitals to 80.5%. Step 10: Referral of mothers for continuous support 1. The administrative staff in 45.5% of hospitals reported that mothers were given information concerning where they can get support if they needed help with feeding their babies after return home. This improved with training of the public hospitals to 71.4%. 2. In 18.2% the facility fostered mother support groups or other community services that provide breastfeeding/ infant feeding support to mothers. This improved with training of the public hospitals to 57.14%. 3. The staff that encourages mothers and their babies to be seen soon after discharge at the facility or in the community by a skilled breastfeeding support person constituted 39.4%. This improved with training of the public hospitals to 71.4%. 4. Printed information distributed to mothers before discharge, on how and where mothers can find help on feeding their babies after return home was found in 15.2% of facilities visited. This improved with training of the public hospitals to 42.85%. 5. One third of mothers (34.25%) reported that they had been given information on how and where to get help with feeding their babies after return home and can mention one type of help available. This improved with training of the public hospitals to 47.7%. Mother Friendly practices 1- Mother friendly (MF) was not included in the policy of the hospital to become Baby Friendly but was informally reported by 36.4% of interviewed admin. staff. This improved with training of the public hospitals to 71.4% and 85.7% for the different items of MF. 2- Clinical staff described at least two recommended practices that can help mothers be more comfortable and in control during labour and birth in 40.4%. This improved with training of the public hospitals to 60.5%. 3- One half (48.5%). of obstetric staff who could list at least three labour and birthing procedures that should not be used routinely but only if required due to complications. This improved with training of the public hospitals to 75.7%. 4- Of staff attending mother’s labor and delivery, 43.8% could describe at least two labour and birthing practices that make it more likely that

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breastfeeding get off to a good start. This improved with training of the public hospitals to 74.05%. International Code of Marketing of Breastmilk Substitutes: implementation and monitoring practices In compliance with the criteria for adherence to the code, the following was found: 1- Employees of manufacturers or distributors of breastmilk substitutes (BMS), bottle, teats or pacifiers have any direct or indirect contact with pregnant women or mothers constituted 81.8% of hospitals visited. This improved with training of the public hospitals to 89.3%. 2- Hospitals that do not receive any free gifts from manufacturers or distributors of BMS, bottles, teats or pacifiers to point of survey were shown in 69.7%. This improved with training of the public hospitals to 82.1%. 3- Mothers and their families were not given marketing materials, samples or gift packs by the facility that include BMS, bottles, pacifiers, other equipment for preparing feeds or coupons were reported by 75.6% of hospitals. This improved with training of the public hospitals to 89.3%. 4- By reviewing records any BMS, including special formulas and other feeding supplies, are purchased by the health care facility for the wholesale price or more in 48.5% of hospitals. This improved with training of the public hospitals to 53.6%. 5- No promotional materials for BMS, bottles, teats or dummies or any other designated products, as per national laws, are displayed or distributed to pregnant women, mothers or staff in72.7% of hospitals. This improved with training of the public hospitals to 89.3% 6- Infant formula cans and prepared bottles are kept out of view in 63.4% of hospitals. This improved with training of the public hospitals to 71.4% 7- About four fifths of the clinical staff (80.4%) were able give two reasons why it is important not to give free formula samples from the infant formula companies to mothers (during an interview with those randomly selected from different departments of the facility). Summary of findings from the Survey of the MCH centers

Criteria for step (1), for having a written policy for breastfeeding promotion, protection and support, ranged from 44.2% to 49.4% for the first four criteria. It was lowest (28.6%) for C5 i.e. having a system for monitoring and improvement of the policy. Criteria for step (2) regarding training in MCH centers ranged from 13% to 26% across all the criteria measured with very little improvement with training. Criteria for step (3) regarding information given to pregnant women about the benefits and management of breastfeeding ranged from 15.6% to 59.7% being considerably low for information given about mother friendly practices and benefits of early and extended fist hour skin-to-skin. These practices improved somewhat with training. Criteria for step (5) about teaching mothers how to breast feed and

Page 18 MCH/MoHP-MCFC-UNICEF BFHI Muti-Center Needs Assessment Survey, 2016 how to express their milk when separated from their babies ranged from 73.2% to 91.3% for C4 to C5 and remained almost the same after exposure to training. Finally step (6) regarding exclusive breastfeeding criteria ranged from 37.4% to 91.2% with little change with training. These conflicting results probably indicate that staff interviewed were not those actually exposed to training and that there is very rapid turnover of staff in the MCH centers versus those in the hospitals who are more or less more stable.

Step “4” of the updated, expanded and integrated Baby Friendly Hospital Initiative (2009) for promoting the optimal and standardized evidence based breastfeeding practices- this practice saves 22% of newborns.

Education, empowerment and opportunities for women and children is a key success strategy for sustainability of the updated, expanded and integrated Baby Friendly Hospital Program and other health interventions.

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INTRODUCTION

Egypt was one of the 12 flagship countries that led the path for promoting, supporting and protecting breastfeeding by making hospitals Baby Friendly many countries all over the world. This started in 1991 when the Inoccenti declaration was announced. At this time UNICEF took the lead in supporting Egypt to lay the foundation of the model for establishing a Baby Friendly environment in all maternity hospitals giving birth and thereafter in maternal and child health centers all over the country.

Egypt achieved tremendous success when it achieved the mid-decade goals in 1995 by going to scale with the BFHI throughout the country and to institutionalize the project as a program with the Primary Health care sector under the department of MCH in MoH. The succession of Ministerial decrees that were released to protect and support breastfeeding from the early 1980s starting form the first one in 1979 that declared the prohibition of promotion in all health facilities paved the way to subsequent resolutions and legislations ending in the modified law for protecting the right of the child and by Her Excellency the Minister of Health obligating all health facilities to implement the Ten steps to Baby Friendly and abide with the International Code of Marketing of Breastmilk Substitutes (ICMBMS).

Since then the mortality rates of infants and children have declined progressively to more than one half indicating that the promotion of breastfeeding did influence the overall health and survival of children.

However the recent Demographic health surveys have shown an ominous sign of decline in the exclusive breastfeeding rates and alerting the health system in Egypt to take active steps to the consequences this grave finding that could have on the future health and survival of our children. Such a finding was to be expected since the tremendous achievements attained in the decade of the 1990s had waned with the turn of the century so that the past decade and a half had resulted in status quo in the implementation and progression of Baby Friendly hospitals despite its integration by the quality department into the accreditation of hospitals and the attainment of some hospitals that were accredited the Baby Friendly status. Such successes were poorly appreciated and were not used to motivate other hospitals or expand with these achievements to other hospitals. Swamped by the burden of acute epidemics and chronic diseases, poor attention was given to nutritional support programs and prevention. This led to a further marginalization of the MCH efforts to promote breastfeeding through other sectors and in particular the Curative and

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Quality sectors of MoH in order to endorse the Baby Friendly in their plans and activities.

Evidence has shown that Baby Friendly hospitals and health facilities that implement the Ten steps for promoting and supporting breastfeeding have had significant effects on successful initiation and continuation of breastfeeding especially in the early months when protecting the health of children have a significant effect on reducing future handicap from serious morbidity and preventing mortality in this period.

The purpose of this survey is to assist the country in understanding the present situational needs for re-establishing the status of Baby Friendly facilities and ignite the momentum for progress towards scaling up to making all health facilities in the country Baby Friendly.

Hospital Policy displayed in the entrance of a hospital in Alexandria

First hour of skin to skin: New interpretation of Step “4”

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AIM OF THE STUDY

The overall goal of the study was to reinforce and guide ongoing interventions of the Ministry of Health & Population (MoHP) as well as the non-governmental organizations (NGOs) working with the ministry in the promotion, protection and support of breastfeeding. The direct objectives of this study included the following: 1. To test and evaluate the UNICEF/WHO BFHI adapted national mock assessment tool in hospitals, medical/family health centers and maternal health service units in Sohag, Qaluibiya, Gharbia and Alexandria. 2. To identify needs of hospitals and maternal and child health (MCH) services to meet the Baby friendly global criteria for the Ten Steps, code compliance and mother friendly practices. 3. To compare and evaluate the effect of training in BFHI in some of the hospitals and MCH health facilities within governorates versus those not exposed to training. This study had other indirect objectives including the following:

1. To define appropriate strategies for implementation of the BFHI in future. 2. To evaluate the training activities and material used for training in both the hospitals and MCH service centers. 3. To define the needs for education and develop communication strategies for promoting optimal breastfeeding practices. 4. To determine the major barriers to implementation of the Ten steps and Code in the health facilities. 5. To identify the potential role other programs can play in strengthening BFHI and improving the health and nutrition of mothers and babies. 6. To formulate strategies that could be useful for expanding the integration of recent updates in breastfeeding research and the scientific basis of the Ten steps in medical and nursing undergraduate and postgraduate university education programs. 7. To build up local and regional networks within the country and outside the country in order to benefit and learn from exchanging experiences in breastfeeding promotion and Baby friendly hospital initiatives.

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METHODOLOGY

This study was carried out by a team of investigators from the MCFC association, Universities of Sohag and Benha with the Ministry of Health central MCH department and health directorates in governorates of Gharbia, Qaluibiya, Sohag and Alexandria in collaboration and under the auspices of the Primary & Preventive Sector of MoH. The field work was completed in a one month period just before Ramadan from mid May 2015 to mid-June, 2015. The study was conducted by expert trained teams from central and local departments of MCH/MoH in cooperation with University staff. In Alexandria governorate by the MCFC association, in Sohag governorate by Community Medicine department in Sohag Faculty of medicine and in Qaluibiya governorate by the Benha Faculty of Medicine. Ten hospitals and 30 primary health care units from each governorate were initially randomly selected from the health facilities fulfilling the following criteria: Selection of Hospitals 1- Availability of maternity and neonatal care services. 2- Any exposure to Baby friendly or breastfeeding promotion. 3- Hospitals that are public governmental hospitals. 4- Good turnover of cases in delivery wards and neonatal units. Selection of MCH 1. Providing antenatal care services or perinatal. 2- Providing Family Planning services. 3- Providing child welfare services and vaccination. 4- Close affiliation to the hospital. 5- High turnover of customers. 6- High birth rate (large catchment area). TOOLS: The data sheets and questionnaires used included the following: Common forms: Hospital/health unit data sheet, observation and review of material forms be used in all facilities. Interviews with clinical and non-clinical staff (nursing and medical- in all departments) be used in all health facilities visited.

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Additional forms for each facility: Forms used to assess delivery practices at district level Form 1: Interviews with mothers of babies less than six weeks for vaginal and caesarean section deliveries in the same hospital (or in nearby hospitals in the same district) from women attending in the target hospital or the randomly selected MCHs. Forms used in the Pediatric department Form 3: Interview with mother of babies in the neonatal care units (NCU). Form 4: Interviews with mothers of babies from up to age 6 months including (10 outpatient clinics and 10 from the inpatient pediatric department of the hospital). Forms used by the MCH centers Form5: Interviews with pregnant women. This is a Multicenter Needs Assessment survey for the BFHI status that was conducted by a group of trained investigators who collected the data under the supervision of the survey supervisors, facilitated by the MCH coordinators in Health Directorate and supported by MCFC members and UNICEF. The survey was conducted in each governorate by a separate team using a unified protocol for the purpose of the multicenter survey that was carried out in 4 governorates [Alexandria, Qaluibiya, Gharbia and Sohag) before expanding to final BFHI assessment in the same governorate and planning mock assessments in the remaining the concerned University. The results of the survey were fed into the UNICEF/WHO BFHI summary forms of assessment, then into the excel sheets and further analyzed for comparative purposes. Description of the methodology: The methodology is based on the monitoring and assessment tools devised by UNICEF and WHO in preparation for scaling with the Baby Friendly hospital Initiative (BFHI) designation process all over the country and in support of the Global Strategy of Infant & Young Child Feeding (GSIYCF). The assessment tool used was adapted from the mock assessment strategy of BFHI that was previously implemented by the Egyptian National Baby Friendly program in the 1990s and was later incorporated into the UNICEF/WHO Updated BFHI (2009) as an optional strategy for countries. The research was approved by the research ethics committee. Method of sampling and tools used The investigators collected the data by interviews with the mothers, staff (doctors and nurses), and from medical records. This multi-source collection of data is based on the BFHI assessment tool. It helps to ensure validity and reliability of the data and to minimize bias.

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The sample size in each of these hospitals was calculated according to the manpower availability for each sector to be interviewed with an upper limit as shown in the coming tool description. The tools included: The tools were adapted from the UNICEF/WHO assessment tool (2006). It included: a hospital facility data sheet, observation sheet and review sheet, interview form for clinical and non-clinical staff, interview forms for mothers in the delivery wards, pregnant women and mothers in special care units. The sample included: 30 clinical staff (10 obstetric nursing, 10 obstetric medical, and 10 neonatal care unit (NCU) (5) nursing (5) and 30 mothers from each hospital (including 10 vaginal, 10 cesarean and 10 from the, NCU/ inpatient pediatric if present) and 10 non-clinical staff from each of the obstetric delivery areas and NCU. (Total = approx. 73 forms). Mothers who are not available in the NCU during the visit were contacted by phone until the sample is complete. In addition to the hospital, three MCH units were randomly selected from each district, using random numbers. The sample included 15 MCH staff and 30 pregnant women and 10 recently delivered breastfeeding mothers attending with their babies -< 6 months- for MCH services), and 10 non-clinical staff comprising health educators, village women leaders and others affiliated to the MCH. There was a health facility data sheet, observation sheet and review sheet for each facility. The numbers recruited were adjusted according to the extent of patient flow. Compilation of data: The study was analyzed using both in a quantitative and qualitative approach. Data was initially compiled in the field using collective interview forms devised by MCFC and this was followed by compilation into the MCFC adapted and translated Arabic UNICEF/WHO “BFHI Summary Sheets” used for interpretation of the assessment according to the BFHI Global Criteria for each of the Ten steps, mother friendly global criteria of the Ten Steps and the code. These reports were handed to the MCH central department in the MoHP. The data for each of the hospitals and MCH centers for each governorate was then compiled into excel sheets and analyzed using percent distribution. This was then presented in descriptive format using percent distribution, distributed and discussed with districts and hospitals during the dissemination workshops held in each governorate. Since the purpose of the analysis was to identify the hospital and MCH service needs for improvement in BFHI implementation, hence the data collected from the staff and mothers, review of hospital records were discussed with the hospital and district officers using the UNICEF summary sheets. The status and needs for improvement of each of the Ten steps and code in the hospital or MCH facility were presented and discussed. This was further reinforced by the individual suggestions and recommendations by the field investigators and central and health directorate MCH officials to get a more comprehensive overview of the needs when presenting our findings in this study.

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Section I: Hospital Survey

STATUS OF GLOBAL BFHI CRITERIA IN HOSPITALS

The findings were collectively analyzed from the individual reports of each hospital in each governorate. The collective findings for the governorate are presented by each of the Ten steps together with the Mother Friendly global criteria and compliance to the code. The list of hospitals in each governorate are presented in Table (1) and by exposure to training is presented in Table (2)

TABLE (1) List of names of 33 hospitals assessed for needs by governorate

SERIES ALEXANDRIA QALUIBIYA GHARBIA (4) SOHAG (10) (10) (9) 1 Abu-Keer Kafr Shoukr Minshawi DH Sohag Gh General H DH 2 DH Samanoud DH Maragha DH District H 3 Dar Ismail Shebin Qanater Kotour Tema DH Maternity H DH DH

4 Elamaria Qanater Kharia Mahalla DH DH General H. DH 5 Ras Eltin Elkhanka DH Sakolta DH General H. 6 Gomhouria H. Kaluib DH Baliana DH 7 Agamy (Salah Shobra Shark Akmiem DH Awadi H. DH 8 Fawzimoaz Benha Children Gihina DH Pediatric H. Specialty Hospital (Bench) 9 Raml Pediatric Benha Gerga DH H. University Hospital 10 Anfoushi Menshah DH Pediatric H. GH: General Hospital, DH: District hospital

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Table (2) List of MoH hospitals in each governorate by exposure to training and date of training in Baby Friendly 20 hour course by the MoH/MCH department: Governorate Hospitals not exposed to Hospitals exposed Date of Training to Training Training Alexandria Abu Keer GH Dar Ismail 2012/13 Goumhoriya GH Ras El Tin GH Salah El Awadi DH ElAmaria DH Bor El Arab DH Fawzi Moaz Ped H Raml Ped H. Anfoushi Ped. H. Gharbia Samanoud DH 2015 Minshawi GH 2015 Kotour DH 2015 Mahalla DH 2015 Qaluibiya Toukh DH Kafr Shokr 2012/2013 Shebin El Khanater DH Kaluib DH 2014/2015 AlKhanka DH Qanater El Kharay DH Shobra Shark GH Benha Children Specialty Hospital Sohag Sohag GH ElMaragha 2012/2013 Baliana DH Sakolta DH Akhmeim DH Gehina DH Tehta DH Tema DH Gerga DH AlMinsha DH TOTAL 24 8 32 MCH/MoH: Maternal and Child Health department in Ministry of Health

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Table (3) Total number of deliveries over the past year in each hospital by governorate

Alexandria Total Qaluibiya Total Gharbia Total Sohag No. Del/y Del/y Del/y Abu-Keer 2244 Kafr 1133 Minshawi 2995 Sohag Gh 8224 General H Shoukr DH DH Borg El 847 Toukh DH 1009 Samanoud 787 Almaragha 2662 Arab District DH DH H Dar Ismail 8838 Shebin 650 Kotour DH 651 Tema DH 0 Maternity H Qanater DH Elamaria 4995 Elkhanka 2082 Mahalla Dh 2535 Tahta Dh 205 General H. Gh Ras Eltin 325 Qaluib Gh 650 Total (4) 6968 Sakolta Dh 400 General H. Gomhouria 2907 Shobra 900 Baliana Dh 3374 H. Shark Dh Agamy 1718 Qanater El 100 Akmiem Dh 640 (Salah Khariya Awadi H. Total (7) 21874 Total (7) 6,524 Gihina Dh 886 GERGA 1864 DH MENSHAH 411 DH TOTAL (10) 18,666 GH: General Hospital, DH: District hospital, Del/y: Deliveries in previous year (2014)

The total number of hospitals were 32 including 28 general and district hospitals providing maternity and neonatal services and 3 pediatric hospitals. The maternity facilities are listed in table (1). The estimated deliveries over the past year ranged from a total of 18,666 in Sohag, 21,874 in Alexandria, 6,968 in 4 hospitals in Gharbia and 6,524 deliveries in the 7 targeted hospitals of Qaluibiya as shown in table (2). All hospitals were governmental public hospitals that serve the district they are therein located and serving (Table 1). They are considered tertiary referral hospitals. They are linked to the primary health care centers and share a common structural administrative system, being officially under the undersecretary of the health directorate of their governorate. They mostly serve the poor or under privileged community, but in some hospitals the private or so called “economical services” are provided that are paid services and allow privacy but are still affordable services. Still the turnover for delivery in these hospitals is low, but has considerably increased with the introduction of quality and the upgrading of the infrastructure and low cost privileged services including the service mix, the

Page 28 MCH/MoHP-MCFC-UNICEF BFHI Muti-Center Needs Assessment Survey, 2016 medical care, diagnostic, therapeutic and specialist staff available in these hospitals. Still the cost of running these hospitals represents a burden for the MoH. The BFHI represents an opportunity for these hospitals as it increases the turn over, decreases the morbidity and mortality and hospital expenditure when complications present in the mother and baby. It also reinforces the infection control measures by allowing baby to be protected by the colostrum and by being with the mother to provide him with nourishment and nurture, observe and warm the baby preventing sepsis, dehydration and hypothermia, the major killers of babies in the early neonatal period. It also reduces neonatal jaundice and thereby the need of admission to the neonatal unit, saving the beds for the more needy preterms and high risk babies and reducing the work load for the nurses, especially with the increasing demand and low supply for qualified intensivist nursing staff.

Unfortunately the important gains and benefits of implementing the Baby Friendly to the hospital, community and country’s economy are poorly understood and underestimated. However, even in developed countries the importance of the BFHI has been realized and is taken seriously as a mandate by the health authorities as a strategy to improve the quality of services, prevent and promote maternal and child health and reduce costs.

Promoting and supporting breastfeeding through the health care system, especially the important role of maternity services, has evolved into the Baby Friendly Hospital Initiative (BFHI) a program that has expanded throughout the world in all countries and has proven its success in ensuring successful initiation and continuation of breastfeeding as well as reducing early neonatal deaths and poor health outcomes from short term communicable and long term noncommunicable diseases. The community component of raising awareness among women both during the antenatal and postnatal periods is important in order to get mother’s cooperation to abide by hospital policies that promote and support breastfeeding rather than resist them.

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Table (4) Total number of staff working in the targeted hospitals by category in each governorate:

Alexandri Do Nrs Qaluibi Do Nrs Gharbia Do Nrs Sohag Do Nrs a . ya . Abu-keer 25 35 Kafr 0 22 Minshawi 186 108 Sohag 6 12 general h shoukr DH GH DH Borg el 24 11 Toukh 63 45 Samanoud 123 96 Marag 28 10 arab DH DH ha DH district h Dar 164 165 Shebin 43 0 0 45 Tema 41 59 Kotour DH ismail Qanater DH maternity DH h Elamaria 46 9 Elkhank 0 0 Mahalla DH 153 116 Tahta 43 8 general h. a GH DH Ras-Eltin 51 6 Kaluib 33 22 Total 462 365 Sakolt 20 20 General GH a DH h. Gomhour 70 32 Shobra 45 10 Balian 36 20 ia GH shark a DH DH Agamy 48 38 Qanater 26 24 Akmie 16 9 (Salah el m DH AlAwadi khariya H. Raml 66 200 Bench 58 100 Gehina 24 28 Ped.. H DH Anfoushi 0 0 Total 268 223 Gerga 63 16 Ped.. H DH Fawzi 52 105 Mensh 8 13 Moaz ah DH Ped. Total 546 601 Total 285 195 Nurs.: nursing staff, GH: general hospital, DH: district hospital, Ped: pediatric,

By examining staff numbers in each hospital, it is clear that the numbers can be easily covered by in-service training programs. Hence the establishment of a system for training inside the health facility can be done by integrating it in the ongoing clinical rounds and staff meetings can be done, once there is commitment and dedication from the administrators to implement the program.

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Table (5) Count of mothers and staff interviewed by category in each district of Sohag governorate:

SOHAG City/District Cl PP Mo NCL Pregnt. MCH MCH T staff Mo in staff CL SS NCU St 1 Sohag GH Sohag 30 10 10 10 10 30 9 109 2 AlMaraghaDH AlMaragha 30 8 10 10 10 20 20 108 3 Tema DH Tema 30 20 10 10 10 20 18 118 4 Tahta DH Tahta 30 4 7 19 10 20 29 119 5 Sakolta DH Sakolta 27 7 10 10 10 10 14 88 6 Baliana DH Baliana 30 8 10 10 10 6 9 83 7 AkhmiemDH Akhmiem 30 8 9 10 10 16 27 110 8 Gehina DH Gehina 30 7 10 8 10 0 20 85 9 Gerga DH Gerga 30 6 10 10 10 5 13 84 10 MenshaDH Menshah 30 7 9 9 10 13 13 91 Total 297 85 95 106 100 140 172 995 Cl St: clinical staff, NCL: non clinical staff, PP Mo: mother in postpartum ward, Mo in NCU: mother with baby in neonatal care unit, MCH Cl st: clinical staff in maternal and child health unit, NCL staff: non clinical staff in MCH units, Pregn.: pregnant woman.

TABLE (6) Count of mothers and staff interviewed by category and district in Qaluibiya governorate:

QALUIBIYA Cl staff PP Mo Mo in NCU NCL staff Pregnt MCH MCH SS Total CL St 1 Kafr Shokr 30 30 3 10 30 30 14 147 2 Toukh 50 20 10 4 20 40 20 164 3 ShebinQanater 30 30 10 10 30 20 25 155 4 Qanater 15 0 0 0 0 17 0 32 5 Elkhanka 30 31 10 10 30 30 24 165 6 Qaluib 30 30 0 10 30 20 25 145 7 Shobrashark 16 10 2 4 30 30 12 104 8 BENCH 20 20 10 20 0 0 0 70 9 BUH 40 30 10 4 0 0 0 84 Total 261 198 55 72 170 187 120 1066 Cl St: clinical staff, NCL: non clinical staff, PP Mo: mother in postpartum ward, Mo in NCU: mother with baby in neonatal care unit, MCH Cl S: clinical staff in maternal and child health unit, NCL SS: non clinical support staff in MCH units, Pregn.: pregnant woman. BENCH: Benha Children Specialty Hospital, BUH: Benha University Hospital.

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Table (7) Count of mothers and staff interviewed by category in the hospitals and districts in Alexandria governorate:

# Hospital District Cl PP Mo Mo in NCL Pregnt MCH MCH Tot (MCHs) staff NCU staff CL SS al St 1 24 10 90 Abu-keer Abu-keer 21 4 4 9 18 2 Agamy Agamy 20 2 0 0 5 20 4 51 3 Anfoushi Gomrouk 17 14 4 10 20 11 0 76 4 Borg elarab Borgelarab 13 10 6 3 9 20 6 67 5 Dar ismail Gharb 1 25 24 4 4 5 14 7 83 6 Fawzimoaz Gharb 2 10 21 10 10 0 0 0 51 7 32 17 12 ElAmaria Elamaria 17 1 6 30 23 6 8 26 2 10 Ras eltin Gomrouk 23 20 6 20 11 8 9 40 0 11 Raml Wasat 24 6 6 17 19 2 10 Gomhouria Gharb 2 13 25 3 3 9 30 0 83 11 Shark SHARK 0 23 0 9 21 0 53 Total 183 218 81 52 133 187 46 900 Cl St: clinical staff, NCL: non clinical staff, PP Mo: mother in postpartum ward, Mo in NCU: mother with baby in neonatal care unit, MCH Cl st: clinical staff in maternal and child health unit, NCL SS: non clinical support staff in MCH units, Pregn.: pregnant woman.

Table (8) Distribution of interviews conducted by category of population and geographic area:

Govs. Cl. staff PP Mo. Mo. in NCL Pregnt. MCH MCH S. Total NCU Staff Cl. Staff Staff 1 Qaluibiya 261 198 55 72 170 187 120 1066 2 Alex 183 218 81 52 133 187 46 900 3 Sohag 297 85 95 106 100 140 172 995 4 Gharbia 40 30 15 30 40 30 30 215 Total 781 531 246 260 443 544 368 3176 Govs.: Governorates, Cl St: clinical staff, NCL: non clinical staff, PP Mo: mother in postpartum ward, Mo in NCU: mother with baby in neonatal care unit, MCH Cl st: clinical staff in maternal and child health unit, NCL SS: non clinical support staff in MCH units, Pregn.: pregnant woman.

Page 32 MCH/MoHP-MCFC-UNICEF BFHI Muti-Center Needs Assessment Survey, 2016

Preparation of the adapted interview forms and summary sheets in Arabic and training the interviewers in each governorate

Orientation meetings with MoHP officials of Qaluibiya, Alexandria and Sohag through MCH/MoHP health directorates in each governorate

Conducting survey in Conducting survey in Conducting survey in the hospitals and the hospitals and the hospitals and MCH in Alexandria MCin Qaluibiya and 4 MCH in Sohag hospitals in Gharbia

Compilation of data in Summary sheets by field investigators & submission of 33 district health reports for the four governorates to central MCH/MoHP

Dissimination and Dissimination and Dissimination and planning workshop in planning workshop in planning workshop in Alexandria Qaluibiya Sohag

Completion of final reports for 3 governorates surveyed for all the hospitals + comprehensive report for the 4 governorates

Page 33 MCH/MoHP-MCFC-UNICEF BFHI Muti-Center Needs Assessment Survey, 2016

STEP 1

The step states that all health facilities serving with mothers and babies should: “Have a written breastfeeding policy that is routinely communicated to all health care staff”

This step is assessed by the following UNICEF/WHO Global criteria: C1.1 A written breastfeeding or infant feeding policy for the hospital exists and is attached. C1.2- The policy covers all the Ten steps adequately and the Code. C1.3- A summary of the policy is displayed in all the areas where mothers and staff are available. C1.4 The summary of the policy is displayed in language(s) and written with wording most commonly understood by both mothers and staff. This criterion was added from the self-appraisal tool for the purpose of the study: C1.5 A mechanism for monitoring and evaluation of the policy is present (in the form of a committee or monitoring system or external auditing system).

Table (9) Distribution of the scores of Baby Friendly criteria for Step (1) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Sohag governorate: Criteria H H2 H3 H4 H5 H6 H7 H8 H9 H10 T % 1 Written 0 0 0 0 0 0 0 0 0 0 0 0 Policy Covers 10 0 0 0 0 0 0 0 0 0 0 0 0 steps & Code Available in 0 0 0 0 0 0 0 0 0 0 0 0 all areas Displayed in 0 0 0 0 0 0 0 0 0 0 0 0 simple language Mechanism 0 0 0 0 0 0 0 0 0 0 0 0 for M&E H1: Sohag GH, H2: Tema DH, H3: Tahta DH, H4: Sakolta DH, H5:Baliana DH, H6: Akhmiem DH, H7: Sakolta DH, H8: Gehina DH, H9: Gerga DH, H10: Menshah DH

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Table (10) Distribution of the scores of Baby Friendly criteria for Step (1) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Qaluibiya governorate in Egypt:

Criteria H1 H2 H3 H4 H5 H6 H7 H8 H9 Total Total No % Written 0 0 100 0 0 0 0 0 100 2 22.2 Policy Covers 10 0 0 100 0 0 0 0 0 0 1 11.1 steps & Code Available in 0 0 100 0 0 0 0 0 0 0 0 all areas Displayed I 0 0 0 0 0 0 0 0 100 1 11.1 simple form Mechanism 0 0 0 0 0 0 0 0 0 0 0 for M&E H1: Kafr shokr, H2: Toukh, H3: Shebin ElQanater, H4: Qanater ElKharaya, H5: ElKhanka, H6: Qaluib, H7: Shobra Shark, H8: Benha Children’s Specialty Hospital (BENCH), H9: Benha University Hospitals (BUH)

Table (11) Distribution of the scores of Baby Friendly criteria for Step (1) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Alexandria governorate in Egypt:

No H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 T % Written 100 100 100 100 100 No 100 100 100 100 9 90 Policy Covers 10 100 0 100 100 0 0 100 100 100 100 6 60 steps+ Code Available in 100 100 100 100 100 0 100 100 100 100 9 90 all areas Displayed 100 0 100 100 100 0 100 100 0 100 6 60 in simple form Mechanism 100 0 No 100 No 0 100 100 0 100 5 50 for M&E H1: AboKeer Hospital, H2: Agamy Hospital, H3: Anfoushi Pediatric Hospital, H4: Borg ElArab Hospital, H5: Dar Ismail Maternity Hospital, H6: Fawzi Moaz Pediatric Hospital, H7: ElAmria Hospital, H8: Ras- Eltin Hospital, H9: Raml Pediatric Hospital, H10: Goumhuria Hospital

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Table (12) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (1) for the Hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt:

Criteria C1.1 C1.2 C1.3 C1.4 C1.5 No. % No. % No. % No. % No. %

Alexandria (10) 9 90 6 60 9 90 6 60 5 50 Gharbia )4) 1 25 1 25 1 25 3 75 1 25 Qaluibiya (9) 2 22.2 1 11.1 0 0 1 11.1 0 0 Sohag (10) 0 0 0 0 0 0 0 0 0 0 Total (33) 11 34.4 9 28.1 11 34.4 9 28.1 7 21.8

100

80

60

40 C1.5 C1.4 20 C1.3 0 C1.2 ALEX. C1.1. GHRB. QALB. SG

Figure (1) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (1) for the Hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt.

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The following table displays the differences between the hospitals exposed to training and those not exposed to training in relation to the global criteria of BFHI for this step:

Table (13) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (1) for hospitals providing maternity and neonatal services in those exposed to training versus those not recently exposed to any training in Baby Friendly:

Criteria C1.1 C1.2 C1.3 C1.4 C1.5

No. % No. % No. % No. % No. % Trained* (8) 2 28.57 2 28.57 2 28.57 3 42.86 2 28.57 No Training 24) 9 37.5 7 29.03 9 37.5 6 25 5 20.8 Total (32) 11 34.4 9 28.1 11 34.4 9 28.1 7 21.8

*Exposed to the UNICEF/WHO 20 hour course for Breastfeeding Promotion in Baby Friendly Hospitals

60 Trained 40

Not Trained 20

0 Not Trained C1.1 Trained C1.2 C1.3 C1.4 C1.5

Figure (2) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (1) for hospitals providing maternity and neonatal services in those exposed to training versus those not recently exposed to any training in Baby Friendly.

At the regional level, table (12) shows that more hospitals in Alexandria and Gharbia are moving towards meeting the global criteria for step 1 as compared to Qaluibiya and Sohag.

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When comparing the effect of training, table (13) shows that there were no significant differences between hospitals exposed to training versus those not recently exposed to training. This indicates that either there was no relationship between training and the implementation of this step, or that training was not efficiently covered for this step. In any case the findings indicate that there is a poor understanding of this step. Also that the purpose of the course is to guide them in how to make their hospital Baby friendly as described in session 15 of the 20 hour course and how to write a policy. But this was not evidently clearly communicated to the hospital staff or that may be the concerned staff were not involved in this session. There was some difference between trained and non-trained hospitals regarding C4 (The summary of the policy is displayed in language(s) and written with wording most commonly understood by both mothers and staff). Some of the hospitals regarded the presence of the Ten steps as a policy, however the “Ten steps” is a guide and does not cover the code or the mother friendly or policies related to common public health priorities for the country, for example as for HIV or HCV or family planning or others. Also the policy needs to be related to the mission of the facility and tailored to the individual services provided by the facility, and depending on its resources, rather than be a restatement of the Ten Steps which is used to guide health facilities on the concept of Baby Friendly practices. For instance if the health facility does not provide maternity services, but has in its mission an educational and public awareness function then this should be clarified in its policy. On the other hand if it is purely a neonatal care service unit or pediatric facility it should describe how it will implement the Ten steps within the framework of its service mix, staff mix and available resources. However, if it is an administrative or health office that serves mothers and babies, the policy should reflect how this office encourages the health units or supervisory staff to achieve the Ten steps including its role in making their office friendly the working breastfeeding mothers, and so on and so forth. Hence the needs for improvement of this step include: 1- Ensuring that each hospital has a written policy in breastfeeding or infant feeding policy that covers all the Ten steps adequately, the Code and is tailored to the facility’s mission and vision. 2- Displaying the summary of the policy in language(s) and attractive illustration format and writing it using wording most commonly understood by both mothers and staff. 3- Installing a mechanism for monitoring and evaluation of the policy.

Page 38 MCH/MoHP-MCFC-UNICEF BFHI Muti-Center Needs Assessment Survey, 2016

STEP 2

The step states that all health facilities serving with mothers and babies should: “Train all health care staff in the skills necessary to implement this policy”

This step is assessed by the following UNICEF/WHO Global Criteria: C2.1. A written curriculum for training in breastfeeding promotion and support is available. C2.2. All Ten Steps and the Code are adequately covered in the training C2.3. Training records indicate that 80% of appropriate clinical staff received training at least 20 hours in duration. C2.4. Training records also indicate that 80% of appropriate clinical staff received at least 3 hours of supervised clinical experience as part of this training. C2.5. Interviews with clinical staff show that they have received the 20 hour course training. C2.6. Interviews with clinical staff show that they are able to answer 4 out of 5 technical questions about breastfeeding support. C2.7. Interviews with nonclinical staff show that they have received an orientation about the policy.

Table (14) Distribution of the scores of Baby Friendly criteria for Step (2) according to the adapted BFHI global criteria in the hospitals providing maternity services in hospitals of Sohag governorate: Step 2 H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 Total Total Criteria No % C2.1 0 0 0 0 0 0 0 0 0 0 0 0 C2.2 0 0 0 0 0 0 0 0 0 0 0 0 C2.3 0 0 0 0 0 0 0 0 0 0 0 0 C2.4 0 0 0 0 0 0 0 0 0 0 0 0 C2.5 54.9 21.4 40 86 33.3 40 29 16.7 8 42 66/187 35.9 C2.6 90 42.8 40 53 58 81 62.9 55.6 33.3 52 104/186 55.9 C2.7 0 20 40 10 20 70 20 40 20 11 23/106 21.7 H1: Sohag GH, H2: Tema DH, H3: Tahta DH, H4: Sakolta DH, H5:Baliana DH, H6: Akhmiem DH, H7: Sakolta DH, H8: Gehina DH, H9: Gerga DH, H10: Menshah DH Cut off of score for meeting criteria 5 is 80% and for criteria 6 is 80% and for criteria 7 is 70%.

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Table (15) Distribution of the scores of Baby Friendly criteria for Step (2) according to the adapted BFHI global criteria in the hospitals providing maternity services in hospitals of Qaluibiya governorate:

Score for H1 H2 H3 H4 H5 H6 H7 H8 H9 Total Total Criteria No % of Step 2 C2.1 0 0 0 0 0 0 0 0 0 0 0 C2.2 0 0 0 0 0 0 0 0 0 0 0 C2.3 0 0 0 0 0 0 0 0 0 0 0 C2.4 0 0 0 0 0 0 0 0 0 0 0 C2.5 23 20 30 13.3 20 26 6.5 0 0 43/239 17.9 C2.6 33 30 60 67 56 57 6 0 5 96/261 36.78 C2.7 23 0 0 0 0 0 0 20 0 7/78 10.3 H1: Kafr shokr, H2: Toukh, H3: Shebin ElQanater, H4: Qanater ElKharaya, H5: ElKhanka, H6: Qaluib, H7: Shobra Shark, H8: Benha Children’s Specialty Hospital (BENCH), H9: Benha University Hospitals (BUH) Cut off of score for meeting criteria 5 is 80% and for criteria 6 is 80% and for criteria 7 is 70%.

Table (16) Distribution of the scores of Baby Friendly criteria for Step (2) according to the adapted BFHI global criteria in the hospitals providing maternity services in hospitals of Alexandria governorate in Egypt:

Criteria of H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 Total Total Step 2 No % Staff oriented in Policy 1 0 0 1 1 0 0 0 1 0 4 40 Orientation is adequate 1 0 0 0 1 0 0 0 0 0 2 20 Written 0 0 0 1 0 0 0 0 0 0 1 10 curriculum available Cur. covers 0 0 0 0 0 0 0 0 0 0 0 0 10 steps & code Staff 80% 0 0 0 0 0 0 0 0 0 0 0 0 trained Clinical 0 0 0 0 0 0 0 0 0 0 0 0 training Staff 61.9 0 29.4 0 76 30 21.7 22 4 7.7 51/ 27.7 confirm 184 training Staff able 19 10 35.3 62 20 60 47 43.5 50 39 66/183 36 to answer Oriented 83.5 0 0 100 57.1 90 0 50 71 50 30/48 62.5 Nonclinical staff H1: AboKeer Hospital, H2: Agamy Hospital, H3: Anfoushi Pediatric Hospital, H4: Borg ElArab Hospital, H5: Dar Ismail Maternity Hospital, H6: Fawzi Moaz Pediatric Hospital, H7: ElAmria Hospital, H8: Ras-Elin Hospital, H9: Raml Pediatric Hospital, H10: Goumhuria Hospital Cut off of score for meeting criteria 5 is 80% and for criteria 6 is 80% and for criteria 7 is 70%.

Page 40 MCH/MoHP-MCFC-UNICEF BFHI Muti-Center Needs Assessment Survey, 2016

The extent to which the hospitals met the criteria for step 2 is displayed in table (17) and figure (4) by governorate:

Table (17) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (2) for the hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt: C C2.1 C2.2 C2.3 C2.4 C2.5 C2.6

No % No. % No. % No. % No. % No. % . Alex 3 30 1 10 1 10 51/ 27. 66/ 36 30/ 62. (10) 184 7 183 48 5 Ghb 3 75 4 100 4 100 43/ 47. 58/ 79 73. 10/ 100 )4) 90 8 4 10 Qal 0 0 0 0 0 0 43/ 17. 96/ 36. 7/ 78 8.9 (9) 239 9 261 8 Sg 0 0 0 0 0 0 66/ 35. 104/ 55. 23/ 21. (10) 187 9 186 9 106 7 Tota 6 18.2 5 15. 5 15. 203/ 29 324/ 45. 70/ 28. l 2 2 700 709 7 242 9 (33) C: Criteria, Alex: Alexandria, Ghb: Gharbia, Qal: Qaluibiya, Sg: Sohag

100

80

60

40 C2.6 C2.5 20 C2.4 C2.3 0 C2.2 ALEX C2.1 GHB QAL SG Figure (3) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (2) for the hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt.

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The following table displays the differences between the hospitals exposed to training and those not exposed to training in relation to the global criteria of BFHI for this step: Table (18) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (2) for hospitals providing maternity and neonatal services in those exposed to training versus those not recently exposed to any training in Baby Friendly: Criteria C2.1 C2.2 C2.3 C2.4 C2.5 C2.6

No. % No. % No % No % No % No. % . . . Trained 4 57. 5 71.4 4 57.1 1 14.3 2 28.6 72/ 45.3 (7) 1 159

Not 1 4.2 1 4.2 0 0 0 0 0 0 131/ 26.6 Trained 493 )24) Total 5 16. 6 19.3 4 12.9 1 3.2 2 6.45 203/ 31.1 (31) 13 6 652 4

100

50 Trained Not Trained 0 C2.1 C2.2 Trained C2.3 C2.4 C2.5 C2.6

Figure (4) : Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (2) for hospitals providing maternity and neonatal services in those exposed to training versus those not recently exposed to any training in Baby Friendly.

Page 42 MCH/MoHP-MCFC-UNICEF BFHI Muti-Center Needs Assessment Survey, 2016

At regional level Gharbia governorate which was totally exposed to training showed a significantly higher levels of attainment in the criteria for step 2 as shown in table (17) and figure (4). At national level, when comparing the trained to the non-trained hospitals (table 18) there was a significant difference in all the criteria showing that training does not make a difference in the implementation of this step, but that it wanes by time considering that one half of these hospitals had a very recent training while the other half were trained at least 12-18 month apart.

There is clearly a need to address this step in all hospitals. The following is suggested:

1- Make achieving BFHI a mandate for the health directorate and not to individual districts or hospitals within the governorate i.e. move from piloting to scaling, using the pilot hospital as a model. 2- Establish a system for training in BFHI within each health directorate, so as to cover all facilities providing maternity and neonatal services within the governorate. 3- Establish accredited training centers inside hospitals or in the district office and appoint a focal person for training in breastfeeding promotion and support. 4- Upgrade the undergraduate curriculum of medical and nursing schools by conducting training workshops to medical and nursing staff and encourage postgraduate professional and degree programs in this field. 5- Integrate the training material in the training department of the Ministry and Health directorates and cross cutting programs and train the responsible officials in the training content by level of staff and responsibilities and supply the resources (both human and educational) for ensuring the quality of training and its sustainability. 6- Develop a system for accrediting sites for clinical training in breastfeeding by setting the criteria for the clinical site and including being a “Baby friendly Hospital” as one of these criteria.

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7- Disseminate the curriculum and training material to all hospitals on regular basis. 8- Develop online and distance learning programs in breastfeeding in the local language. 9- Formulate a facility based Breastfeeding committee or task force that is responsible for planning training schedules and follow-up of training, and ongoing educational activities (seminars, clinical conferences and training workshops). 10- Establish a system for orienting new staff in the hospital policies as soon as they arrive. 11- Expose older staff to continuing education, based on adult learning needs, that are regularly conducted in the facility (daily rounds, staff meetings, conferences or webinars). 12- Strengthening supervision of training and educational activities through upgrading and updating monitoring and evaluation by the concerned departments and central offices in the MoHP and its partners in various sectors, while ensuring that CME is not lead by pharmaceutical companies and industry. 13- Setting up of an incentive system for motivating and encouraging continued education for example giving our awards for staff who organize meetings in breastfeeding, or conduct research or attend a certain number of hours CME through conferences or other innovative educational or research activity that can make a difference in the improving the implementation of Baby friendly in the facility or at district or country level. For example a physician can get an award for making his private clinic Baby friendly or because he helped another hospital to become Baby Friendly or developed a monitoring system or IT application for his hospital or set up an educational system for primary health care staff.

Page 44 MCH/MoHP-MCFC-UNICEF BFHI Muti-Center Needs Assessment Survey, 2016

STEP 4

The step states that all health facilities serving with mothers and babies should: “Initiate breastfeeding immediately after birth through continued uninterrupted direct skin-to-skin contact between mother and baby for at least one hour or up to first breastfeed and encourage mothers to recognize when their babies readiness to breastfeed, offering help if needed”

The Step was assessed by the following UNICEF/WHO Global Criteria: C4.1.In the labour ward if a birth is observed it should show how staff routinely gave the baby to the mother and perform skin to skin and to hold skin to skin for one hour. C4.2. Interviews with mothers with normal vaginal delivery (NVD) of cesarean (CS) with spinal or epidural anesthesia show that they were given their baby within 5 minutes of birth. C4.3. Interviews with mothers delivered by CS with general anesthesia (GA) show that they have were given their baby within 5 minutes of birth. C4.4. Interviews with mothers with NVD or CS with spinal or epidural anesthesia show that they were given their baby to hold skin- to-skin (STS) for one hour during which baby and mother were supported to initiate breastfeeding. C4.5. Interviews with mothers with delivered by CS with GA show that they have were given their baby to hold STS for one hour on recovery during which baby and mother were supported to initiate breastfeeding. C5.6 Interviews with all mothers delivered by NVD or CS with spinal or GA show that an observer was assigned to the mother while doing STS and they encouraged her to recognize her babies’ readiness to breastfeed while performing STS. C4.7. Interviews with mothers with babies in neonatal care unit (NCU) show that they were encouraged to hold their baby STS.

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Table (19) Distribution of the scores of Baby Friendly criteria for Step (4) according to the adapted BFHI global criteria in the Hospitals providing maternity services in hospitals of Sohag governorate: Criteria H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 Total Total of Step No % 4 C4-1 0 0 0 0 0 0 0 0 0 0 0 0 C4-2 80 62 100 50 42 50 75 71.4 66.7 71 52/75 69.3 C4-3 0 0 0 0 0 0 0 0 0 0 0/10 0 C4-4 70 37 40 50 28.6 50 50 42.85 66.7 57 37/75 49.3 C4-5 0 0 0 0 0 0 0 0 0 0 0/10 0 C4-6 70 50 0 0 28.6 62 25 28 33.3 28 48/210 36.6 4-7 0 0 0 0 60 0 0 0 0 26/71 6/55 10.9 H1: Sohag GH, H2: Tema DH, H3: Tahta DH, H4: Sakolta DH, H5:Baliana DH, H6: Akhmiem DH, H7: Sakolta DH, H8: Gehina DH, H9: Gerga DH, H10: Menshah DH Cut off of score for meeting criteria 4.1 75% OR no deliveries observed, 4.2 No score, 4.3 80%, 4.4 50% 4.5 – 4.6 80% on one item and 70% on the other, 4.7: 80%.

100

80 60 40

20 C4.7 C4.5 0 C4.3 H1 H2 H3 H4 H5 H6 C4.1 H7 H8 H9 H10

Figure (5) Distribution of the scores of Baby Friendly criteria for Step (4) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Sohag governorate.

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Table (20) Distribution of the scores of Baby Friendly criteria for Step (4) according to the adapted BFHI global criteria in the Hospitals providing maternity services in hospitals of Qaluibiya governorate: Criteria H1 H2 H3 H4 H5 H6 H7 H8 H9 Total Total of Step 4 No % (percent) C4-1 No No No No No No No No No 0 0 C4-2 53.3 50 53.3 0 53.3 73.3 25 0 33 92/198 46.5 C4-3 0 0 0 0 0 0 100 0 0 2/3 66.7 C4-4 6 0 23.3 0 26.7 0 0 0 0 17/198 8.5 C4-5 0 0 0 0 0 0 0 0 0 2/3 66.7 C4-6 6 25 30 0 33.3 10 100 0 22.5 48/210 24 4-7 0 0 0 0 60 0 0 0 0 6/55 10.9 H1: Kafr shokr, H2: Toukh, H3: Shebin ElQanater, H4: Qanater ElKharaya, H5: ElKhanka, H6: Qaluib, H7: Shobra Shark, H8: Benha Children’s Specialty Hospital (BENCH), H9: Benha University Hospitals (BUH) Cut off of score for meeting criteria 4.1 75% OR no deliveries observed, 4.2 No score, 4.3 80%, 4.4 50% 4.5 – 4.6 80% on one item and 70% on the other, 4.7: 80%.

100 C4.1 80 C4.2 60 C4.3

40 C4.4 C4.5 20 C4.7 C4.6 C4.5 0 C4.3 C4.7 H1 H2 H3 C4.1 H4 H5 H6 H7 H8 H9

Figure (6) Distribution of the scores of Baby Friendly criteria for Step (4) according to the adapted BFHI global criteria in the hospitals providing maternity services in Qaluibiya governorate.

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Table (21) Distribution of the scores of Baby Friendly criteria for Step (4) according to the adapted BFHI global criteria in the hospitals providing maternity and pediatric services in Alexandria governorate in Egypt:

Criteria H1 H2 H3* H4 H5 H6 H7 H8 H9 H10 Total Total of Step No % 4 C4-1 0 0 0 0 0 0 0 0 0 0 C4-2 15/25 0/2 1/7 1/3 24/24 3/5 0/4 4/8 48/78 37.14 60 0 14 33.3 100 60 0 50 C4-3 0 0 2/3 0 0 0 0 0/3 2/6 33.3 67 C4-4 15/25 0/2 0/7 0/3 0/24 0/5 0/4 0/8 15/78 19.2 60 0 0 0 0 0 0 0 C4-5 0 0 0/3 0 0 0 0 0/3 0/6 0 C4-6 25/25 0/2 1/10 3/3 0/24 0/5 1/4 20/40 0/11 50/ 30.5 100 0 10 100 0 0 25 50 0 124

C4-7 4/4 0 0 0/3 4/4 0/6 0/1 0/6 0/8 0/3 4/35 9.3 100 0 100 0 0 0 0 0 H1: AboKeer Hospital, H2: Agamy Hospital, H3: Anfoushi Pediatric Hospital (mothers delivered in Shatby University or private), H4: Borg ElArab Hospital, H5: Dar Ismail Maternity Hospital, H6: Fawzi Moaz Pediatric Hospital, H7: ElAmria Hospital, H8: Ras-ElTin Hospital, H9: Raml Pediatric Hospital, H10: Goumhuria Hospital Cut off of score for meeting criteria 4.1 75% OR no deliveries observed, 4.2 No score, 4.3 80%, 4.4 50% 4.5 – 4.6 80% on one item and 70% on the other, 4.7: 80%.

#REF!

100 C4-2

80 C4-3 C4-4 60 C4-5 40 C4-7 C4-5 C4-6 20 C4-3 C4-7 0 #REF! H1 H2 H3 H4 H5 H6 H7 H8 H9 H10

Figure (7) Distribution of the scores of Baby Friendly criteria for Step (4) according to the adapted BFHI global criteria for hospitals providing maternity and neonatal services in Alexandria governorate in Egypt.

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The extent of achievement of the above criteria by hospitals is displayed in table (22) and figure (8) by governorate. Criteria related to giving their baby to hold immediately after birth or to hold STS for one hour CS with GA were lowest. Only one in every five mothers with NVD or CS with spinal or epidural anesthesia were given their baby to hold STS for one hour, mostly in the trained hospitals. Criteria (C4.6), for encouraging mothers to recognize baby’s readiness to feed while on STS, was practiced in one third of the cases.

Table (22) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (4) for the Hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt:

C C4.2 C4.3 C4.4 C4.5 C4.6 C4.7 No. % No. % No. % No. % No. % No. % Alex 69/ 183 37.7 7/31 22.5 22/ 183 12 0/31 0 71/ 233 30.5 4/43 9.3 (10) Ghb 10/ 13 76.9 1/2 50 11/ 17 64.7 0/2 0 16/ 18 88.9 4/10 40 )4) Qal 92/198 46.5 2/3 66.7 17/ 198 8.5 2/3 66.7 48/ 200 24 6/55 10.9 (9) Sg 52/ 75 69.3 0/10 0 37/ 75 49.3 0/ 0 26/ 71 36.6 52/ 98 53.1 (10) 10 T 220/411 53.5 10 21.7 87/ 473 18.4 2/ 4.3 161/ 30.8 66/206 32.04 (33) /46 46 522 C: criteria, Alex: Alexandria, Ghb: Gharbia, Qal: Qaluibiya, Sg: Sohag

100 80 60

40 C4.7 C4.6 20 C4.5 C4.4 0 C4.3 C4.2 ALX GHB QAL SG

Figure (8) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (4) for the Hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt.

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The following table displays the differences between the hospitals exposed to training and those not exposed to training in relation to the global criteria of BFHI for this step. Improvement with training indicated that five in every ten versus two in every 10 babies of mothers with NVD or CS with spinal or epidural anesthesia practiced STS for one hour, and thereby had a 22% less chance of mortality.

Table (23) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (4) for the Hospitals exposed to BFHI training and those not exposed: C4.2 C4.3 C4.4 C4.5 C4.6 C4.7 No. % No. % No. % No. % No. % No. % Traine 55/ 73.3 1/2 50 16/ 20.2 0/ 0 22/ 27.5 14/27 58.9 d (7) 75 79 5 2 80

Not 135/ 58.4 4/ 19 21.1 64/ 27.7 2/ 10.5 101/ 36.7 56/ 37.6 trained 231 231 19 275 3 149 24) Total 190/ 62.0 5/21 23.8 80/ 25.8 2/21 9.5 123/35 34.6 70/ 39.8 (31) 306 9 1 310 5 5 176

NB: Differences in the total numbers interviewed between tables 21 and 22 in the total are related to exclusion of the private sector in in table 22.

80 70 C4.2 60 C4.3 50 C4.4 40 C4.7 C4.6 C4.5 30 C4.5 C4.6 20 C4.4 10 C4.3 C4.7 0 C4.2 Trained Not Trained

Figure (9)) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (4) for the Hospitals exposed to BFHI training and those not exposed.

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This step is integral to the success of Baby friendly practices and has therefore been included in the recently Updated, Expanded BFHI Ten steps. Although, none of the hospitals at district or governorate level were able to meet the full global criteria set for this step, but with exposure to training, there was a clear difference between the groups indicating that training did significantly change practice towards implementing this step. The difference could only be calculated for the deliveries without anesthesia i.e. NVD or cesarean section (CS) with spinal anesthesia but not for CS with general anesthesia (GA), since the latter practice was not common and even in those exposed it was not practiced. The reason for the latter finding; is that the baby exposed to CS with GA was taken directly to the neonatal care unit (NCU) for resuscitation or observation.

At governorate level, the practice of giving the baby to the mother to hold and establish eye to eye contact immediately after birth, when the mother was awake (i.e. NVD and spinal without GA), was 53% being highest in Sohag hospitals where it was practiced in 3 out of every 4 babies.

The most deficient global BFHI criteria of this step was keeping the baby skin-to-skin (STS) with the mother for one hour i.e. first hour STS (FHSTS) and also bringing her attention to her baby’s emerging feeding cues or readiness to feed as baby crawls towards her breast when placed prone on her chest STS, even if covered, as long as the bare chest of both are in contact. Maternal reflexes emerge even if the mother is drowsy and she spontaneously responds to holding her baby in protection indicating awakening and strengthening her innate maternal nurturing attributes.

The practice of early STS was highest in Gharbia hospitals (88.9%) and lowest in the Qaluibiya (21.8%) ones, but there was no guarantee that they were left for one hour or up to the first feed. The former were recently exposed to training in BFHI, and shows the impact of training on changing attitudes and practices towards the practice of early first hour skin to skin between mother and baby. The major obstacle facing hospitals to meet this step which is pivotal to meeting the BFHI criteria is the cultural aspects related to having the mother expose her bare chest in the operating theater. If mother is provided with privacy and decent clothes this might help the practice to be more accepted and fulfilled. There is also reluctance of the staff to perform it, as they are more concerned with medical procedures.

However, when some hospital staff did perform STS, it was done briefly and not extended for one hour. Hence there is a need to move from brief periods of early STS to extended and continuous uninterrupted STS up to the first suckle with a guarantee that most of the pre- feeding reflexes have appeared and baby has thus developed the correct mode of feeding.

It is important for each hospital to realize the importance of this step in lowering neonatal mortality by decreasing hypothermia and stabilizing the breathing and oxygenation of these babies thereby preventing asphyxia and lowering hospital acquired cross infection; as baby acquires mother’s skin flora to which he be immunized through colostrum. Hospital staff

Page 51 MCH/MoHP-MCFC-UNICEF BFHI Muti-Center Needs Assessment Survey, 2016 need to devise their own protocols to implement this step. Prior preparation of the mother is important either during antenatal education or antepartum when admitted to the hospital. She must be reassured her privacy and decency and the joy of embracing her baby STS in this critical period of bonding which save lives, treat and prevent hypothermia as well as enhance baby’s development and paves the way to a successful breastfeeding experience. Mothers also benefits as it stimulates uterine contraction and complete separation of placenta thus preventing postpartum bleeding.

The needs for hospitals to meet this step are:

Training in this step is essential as it clearly does result in a huge difference in practice, hence all hospitals should be exposed to intensive training in this step which is the core practice in BFHI and is the new interpretation of step 4 which was not present in the BFHI stated in the 1990s.

Integration of the importance of pre-feeding reflexes in the pediatric and neonatal curricula of medical and nursing staff can assist in graduated medical and nursing staff to accept and integrate this in their practice. Also to train pediatric, neonatal and obstetric residents to practice this during their residency programs as a part of their resuscitation or emergency programs to save the lives of neonates.

In the antepartum ward: Prepare mothers to request and accept to be given their baby to hold immediately after birth if they are awake or as soon as they recover from their sedation. Emphasize to them the importance of having appropriate clothing and reassure them of having privacy when keeping their baby skin-to-skin contact up to the first breastfeed or for at least one hour showing her the importance of the baby showing prefeeding responses that indicate intact brain functions .

In the Labor ward and operating theater: The practice should be explained to medical staff through protocols in the labor ward and the recovery rooms of operating theaters. Appropriate clothing should be made available – in this case the mother can wear a double gown to hold her baby in skin-to-skin in a clean environment.

NCU: All babies admitted to the NCU should be assisted in their first breastfeed by being placed skin to skin for one hour before they breastfeed. Mother should be encouraged to practice skin to skin care whenever she visits or spends time with her baby in the NCU unit. This should also be made available for mothers visiting the neonatal care units- the same gown staff wear can be used for mothers so they can hold and care for their baby in skin to skin care (STSC) and Kangaroo Mother Care (KMC).

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STEP 5

The step states that all health facilities serving with mothers and babies should: “Show mothers how to breastfeed and how to maintain lactation”

This step is assessed by the following UNICEF/WHO Global Criteria:

C5.1. Mothers who are at risk receive adequate help and guidance on how to breastfeed. C5.2. Mothers who are unable to breastfeed are shown how to prepare and feed breastmilk substitutes, the demonstrations were accurate, complete, and included the mother giving a “return demonstration” C5.3. Interviews with clinical staff showed that they teach mothers about positioning and attachment and describe correct techniques for both or, if they do not teach, describe to whom to refer mothers. C5.4. Interviews with clinical staff showed that they reported that they teach mothers hand expression and gave adequate descriptions and demonstrations of what they would teach mothers or, if they do not teach, describe to whom to refer mothers. C5.5. Interviews with clinical staff show that they report that they teach mothers who are unable to breastfeed how to give a safe substitute and also inform them of the hazards of not breastfeeding. (Applicable in high risk HIV areas). C5.6. Interviews with mothers show that staff offered further help with breastfeeding the next time the baby was fed or within 6 hours of delivery. C5.7. Interviews with mothers show that they were able to demonstrate correct positioning and attachment with their baby. C5.8. Interviews with mothers show that staff offered further help on how to express milk or gave them a handout on how to do so. C5.9. Interviews with mothers who are unable to breastfeed show that they were instructed on how to prepare formula. (Applicable to high risk HIV areas) C5.10. Interviews with mothers of babies in special care report that, if they were breastfeeding or planning to do so, they had been offered help to start their breastmilk coming and to keep up the supply within 6 hours of their babies’ births. C5.11. Interviews with mothers of babies in special care report that, if they were breastfeeding or planning to do so, they had been offered help on how to express their milk safely. C5.12. Interviews with mothers of babies in special care were able to demonstrate the correct way of milk expression. C5.13. Interviews with mothers of babies in special care report that, if they were breastfeeding or planned to do so, they had been told they need to breastfeed or express their milk 6 times or more every 24 hours to keep up the supply.

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Table (24) Distribution of the scores of Baby Friendly criteria for Step (5) according to the adapted BFHI global criteria in the Hospitals providing maternity services in hospitals of Sohag governorate:

Criteria H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 Total Total of Step No % 5 C5-1 0 0 0 0 0 0 0 0 0 0 0 C5-2 0 0 0 0 0 0 0 0 0 0 0 C5-3 70 66.7 56 86 70 60 70 211/297 71.04 83 86 53 C5-4 100 76.7 55 83.3 100 73.3 90 249/297 83.8 83 96 76 C5-5 93 100 93 100 88 100 86.7 96.7 96.7 100 284/297 95.6 C5-6 80 62 0 50 42 83 40 40 50 33.3 32/67 47.76 C5-7 80 75 40 50 57 83 60 60 33.3 66.7 41/67 61.2 C5-8 60 75 0 0 28 50 60 60 33.3 50 28/67 41.79 C5-9 0 0 0 0 0 100 66.7 100 0 100 7/8 87.5 C5-10 70 50 30 42.8 40 50 44.4 50 20 33.3 41/95 43.2 C5-11 60 50 40 42.8 30 40 33.3 30 20 42 36/93 38.7 C5-12 83 60 75 33.3 33.3 66.7 28.57 66.7 100 75 26/43 60.5 C5-13 70 70 40 42.8 40 50 44.44 50 40 57 47/93 50.5 H1: Sohag GH, H2: Tema DH, H3: Tahta DH, H4: Sakolta DH, H5:Baliana DH, H6: Akhmiem DH, H7: Sakolta DH, H8: Gehina DH, H9: Gerga DH, H10: Menshah DH Cut off of score for meeting criteria 3 to 13 are: 5.1: “Yes”; 5.2: 75% or no demonstrations could be observed for an acceptable reason; 5.3 – 5.5: 80% on 2 items, 50% on 1 item; 5.6 – 5.10: 80% on 3 items, 50% on 2 items; 5.11 – 5.14: 80% on 3 items, 50% on 1 item.

H 100 1 H 50 H9 2 H7 H5 H 0 H3 3

H1 H

C5-1

C5-2 C5-3

C5-4 4

C5-6

C5-5

C5-7 C5-8 C5-9 H1: Sohag GH, H2: Tema DH, H3: Tahta DH, H4: Sakolta DH, H5:Baliana DH, H6: Akhmiem DH, H7: Sakolta DH, H8: Gehina DH, H9: Gerga DH, H10: Menshah DH Figure (10) Distribution of the scores of Baby Friendly criteria for Step (5) for maternity wards (positioning and attachment) according to the adapted BFHI global criteria in Sohag governorate.

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100

50

0 C5.13 C5.12 H1 H2 C5.11 H3 H4 H5 H6 C5.10 H7 H8 H9 H10

C5.10 C5.11 C5.12 C5.13

H1: Sohag GH, H2: Tema DH, H3: Tahta DH, H4: Sakolta DH, H5:Baliana DH, H6: Akhmiem DH, H7: Sakolta DH, H8: Gehina DH, H9: Gerga DH, H10: Menshah DH Figure (11) Distribution of the scores of Baby Friendly criteria for Step (5) for neonatal care units (milk expression) according to the adapted BFHI global criteria in Sohag governorate. Table (25) Distribution of the scores of Baby Friendly criteria for Step (5) according to the adapted BFHI global criteria in the hospitals providing maternity services in hospitals of Qaluibiya governorate: Criteria of H1 H2 H3 H4 H5 H6 H7 H8 H9 Total Total Step 5 No % C5-1 0 0 0 0 0 0 0 0 0 0 0 C5-2 0 0 0 0 0 0 0 0 0 0 0 C5-3 83 96 80 40 70 93 70 100 40 209/275 80.5 C5-4 43 24 43 13.3 100 26.7 100 20 12.5 117/275 50.2 C5-5 90 62 66.7 73.3 86.7 43.3 93 65 25 179/275 72.6 C5-6 63 36.7 66.7 0 36.7 10 90 0 0 73/210 34.7 C5-7 93 90 100 97 100 90 65 67 186/210 88.57 C5-8 23 27 3 0 17 13 0 0 0 25/210 11.9 C5-9 80 27 0 0 20 0 0 0 0 20/104 19.23 C5-10 0 0 40 0 20 0 0 0 0 6/55 10.9 C5-11 0 0 40 0 20 0 0 0 0 6/30 20 C5-12 100 40 70 0 20 0 0 0 0 23/49 46.9 C5-13 0 0 80 0 10 0 0 0 0 9/53 16.9 H1: Kafr shokr, H2: Toukh, H3: Shebin ElQanater, H4: Qanater ElKharaya, H5: ElKhanka, H6: Qaluib, H7: Shobra Shark, H8: Benha Children’s Specialty Hospital (BENCH), H9: Benha University Hospitals (BUH) Cut off of score for meeting criteria 3 to 13 are: 5.1: “Yes”; 5.2: 75% or no demonstrations could be observed for an acceptable reason; 5.3 – 5.5: 80% on 2 items, 50% on 1 item; 5.6 – 5.10: 80% on 3 items, 50% on 2 items; 5.11 – 5.14: 80% on 3 items, 50% on 1 item.

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C5-1 100 C5-2 80 C5-3 60 C5-4 40 C5-9 C5-5 20 C5-7 C5-5 C5-6 0 C5-3 C5-7 H1 H2 H3 H4 C5-1 H5 H6 H7 C5-8 H8 H9 H1: Kafr shokr, H2: Toukh, H3: Shebin ElQanater, H4: Qanater ElKharaya, H5: ElKhanka, H6: Qaluib, H7: Shobra Shark, H8: Benha Children’s Specialty Hospital (BENCH), H9: Benha University Hospitals (BUH) Figure (12) Distribution of the scores of Baby Friendly criteria for Step (5) for maternity wards (positioning and attachment) according to the adapted BFHI global criteria in Qaluibiya governorate.

100 80 C5.10 60 C5.11 40 20 C5.12 0 C5.13 C5.12 H1 H2 H3 C5.10 H4 H5 H6 H7 H8 H9

Figure (13) Distribution of the scores of Baby Friendly criteria for Step (5) for neonatal care units (milk expression) according to the adapted BFHI global criteria in Qaluibiya governorate.

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Table (26) Distribution of the scores of Baby Friendly criteria for Step (5) according to the adapted BFHI global criteria in the Hospitals providing maternity services in hospitals of Alexandria governorate: Criteria H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 Total Total of Step 5 number % C5-1 Yes Yes Yes Yes No Yes No No No No 5 50 C5-2 No Yes No Yes No No No No No No 2 0 C5-3 21/30 13/20 11/17 10/13 20/24 7/10 8/18 15/23 11/24 9/13 125/ 67.9 70% 65% 65% 77% 83% 70% 44% 65% 46% 69% 192 C5-4 30/30 0/20 6/17 2/13 0/24 8/10 6/18 12/23 14/24 3/13 81/ 46 100% 0% 35% 15.3% 0% 80% 33.3% 52% 58% 23.1% 192 C5-5 28/30 20/20 6/17 4/13 16/16 10/10 11/18 19/23 23/24 12/13 149/ 80.7 93% 100% 35% 31% 100% 100% 61.1% 83% 96% 92.1% 184 C5-6 23/24 0/2 4/10 0/3 9/24 2/10 4/5 0/4 5/17 1/9 48/ 42.9 92% 0 40% 0 37.5% 20% 80% 0 29% 11% 109 C5-7 12/25 0/2 4/10 0/3 0/24 2/10 4/5 1/4 7/17 2/9 32/ 109 28.9 48% 0 40% 0 0 20% 80% 25% 41.1% 22.2 C5-8 25/25 ½ 2/10 0/3 0/24 0/10 1/5 0/4 4/17 1/9 34/ 29.8 100% 50% 20% 0 0 0 20% 0% 23.5% 11% 109 C5-9 0/25 0/0 4/4 0/0 0/24 0/0 0/0 0/0 1/17 1/1 6/71 8.5 0 100% 0 0 0 0 6% 100% C5-10 1/4 0/0 1/4 1/1 0/4 0/10 0/1 3/6 2/6 1/3 6/39 8.6 25% 25% 100% 0 0 0 50% 33.3% 33.3% C5-11 0/4 0/0 ¼ 0/3 0/4 1/10 0/1 3/6 6/6 0/3 11/41 18.1 0 0 25% 0 0 10% 0 50% 100% 0 C5-12 0/4 0/0 0/4 0/3 0/4 1/10 0/1 0/6 4/6 0/3 5/41 7.2 0 0 0 0 0 10% 0 0 66.7 0 C5-13 4/4 0/0 0/4 0/3 4/4 2/20 0/1 3/6 4/6 0/3 17/41 21.7 100% 0 0 0 100% 20% 0 50% 66.7 0 H1: AboKeer Hospital, H2: Agamy Hospital, H3: Anfoushi Pediatric Hospital (mothers delivered in Shatby University or private), H4: Borg ElArab Hospital, H5: Dar Ismail Maternity Hospital, H6: Fawzi Moaz Pediatric Hospital, H7: ElAmria Hospital, H8: Ras El ElTin Hospital, H9: Raml Pediatric Hospital, H10: Goumhuria Hospital

Cut off of score for meeting criteria 3 to 13 are: 5.1: “Yes”; 5.2: 75% or no demonstrations could be observed for an acceptable reason; 5.3 – 5.5: 80% on 2 items, 50% on 1 item; 5.6 – 5.10: 80% on 3 items, 50% on 2 items; 5.11 – 5.14: 80% on 3 items, 50% on 1 item.

Cup feeding baby with expressed breastmilk in NCU

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C5-3 C5-4 100 C5-5 80 C5-6 60 C5-9 40 C5-7 C5-7 20 C5-5 C5-8 0 C5-3 C5-9 H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 H1: AboKeer Hospital, H2: Agamy Hospital, H3: Anfoushi Pediatric Hospital (mothers delivered in Shatby University or private), H4: Borg ElArab Hospital, H5: Dar Ismail Maternity Hospital, H6: Fawzi Moaz Pediatric Hospital, H7: ElAmria Hospital, H8: Ras El ElTin Hospital, H9: Raml Pediatric Hospital, H10: Goumhuria Hospital

Figure (14) Distribution of the scores of Baby Friendly criteria for Step (5) according to the adapted BFHI global criteria in the Hospitals for maternity services in Alexandria governorate in Egypt.

100 80

H10 60 H9 H8 H7 40 H6 H5 20 H4 H3 0 H2 C5-10 H1 C5-11 C5-12 C5-13

H1: AboKeer Hospital, H2: Agamy Hospital, H3: Anfoushi Pediatric Hospital (mothers delivered in Shatby University or private), H4: Borg ElArab Hospital, H5: Dar Ismail Maternity Hospital, H6: Fawzi Moaz Pediatric Hospital, H7: ElAmria Hospital, H8: Ras El ElTin Hospital, H9: Raml Pediatric Hospital, H10: Goumhuria Hospital

Figure (15) Distribution of the scores of Baby Friendly criteria for Step (5) according to the adapted BFHI global criteria in the Hospitals for neonatal services in Alexandria governorate in Egypt.

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The extent to which the hospitals met the above criteria of this step is displayed in table (27) and figures (16,17 and 18) by governorate:

Table (27) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (5) for the 31 public hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt:

Criteria Alex (10) Gharbia (4) Qaluibiya (9) Sohag (10) Total (33) of Step No. % No. % No. % No. % No. % 5 C5-1 4 40 3 75 0 0 10 100 17 51.5 C5-2 1 10 1 25 0 0 10 100 12 36.4 C5-3 146/215 67.9 71/89 79.7 209/275 80.5 211/297 71.04 637/876 72.7 C5-4 99/ 215 46 67/89 75.3 117/275 50.2 249/297 83.8 532/876 60.7 C5-5 167/207 80.7 88/89 98.8 179/275 72.6 284/297 95.6 718/ 868 82.7 C5-6 49/114 42.9 17/22 77.3 73/210 34.7 32/67 47.8 171/413 41.4 C5-7 33/114 28.9 16/18 88.9 186/210 88.57 41/67 61.2 276/409 67.5 C5-8 34/114 29.8 16/21 76.2 25/210 11.9 28/67 41.8 103/412 25 C5-9 6/71 8.5 0/0 0 20/104 19.23 7/8 87.5 33/183 18.03 C5-10 7/81 8.6 6/10 60 6/55 10.9 41/95 43.2 60/241 24.9 C5-11 15/83 18.1 10/12 83.3 6/30 20 36/93 38.7 67/218 30.7 C5-12 6/83 7.2 8/12 66.7 23/49 46.9 26/43 60.5 53/187 28.3 C5-13 18/83 21.7 5/12 41.7 9/53 16.9 47/93 50.5 79/241 32.8 Cut off of score for meeting criteria 3 to 13 are: 5.1: “Yes”; 5.2: 75% or no demonstrations could be observed for an acceptable reason; 5.3 – 5.5: 80% on 2 items, 50% on 1 item; 5.6 – 5.10: 80% on 3 items, 50% on 2 items; 5.11 – 5.14: 80% on 3 items, 50% on 1 item.

100 80 60 40 20 C5.5 0 C5.4 ALX C5.3 GHB QAL SG

Figure (16) Comparison of the scores of Baby Friendly criteria related to interviews with clinical staff on they show mothers how to breastfeed and maintain their supply in the four governorates.

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100 80 60 40 20 C5.8 0 C5.7 ALX GHB C5.6 QAL SG

Figure (17) Comparison of the scores of Baby Friendly criteria related to interviews with mothers on whether they are supported by staff on how to breastfeed and express their milk to maintain their supply in the four governorates.

90 80 70 60 50 40 30 20 C5.13 10 C5.12 0 C5.11 ALEX C5.10 GHB QAL SG

Figure (18) Comparison of the scores of Baby Friendly global criteria related to interviews with mothers with babies in special care unit on how they are supported by staff to breastfeed and express their milk to maintain their supply in the 4 governorates.

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The following table displays the differences between the hospitals exposed to training and those not exposed to training in relation to the global criteria of BFHI for this step:

Table (28) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (5) for the 31 public hospitals providing maternity and neonatal services by exposure to training in Baby friendly:

Score for Criteria Trained (7) Not Trained (24) Total (31) of Step 5 No. % No. % No. % 5-1 5 71.4 14 58.3 19 61.29 5-2 2 28.57 11 45.8 13 41.9 5-3 142/173 82.08 438/620 70.65 580/793 73.14 5-4 109/173 63 396/620 63.87 505/793 63.68 5-5 161/165 97.58 516/620 83.22 677/785 86.24 5-6 50/84 59.5 113/266 42.48 163/250 65.2 5-7 50/80 62.5 185/266 69.55 235/346 67.9 5-8 29/83 34.9 74/264 28.03 103/347 29.68 5-9 8/34 23.5 25/135 18.52 33/169 19.53 5-10 11/27 40.74 51/150 34 62/177 36.7 5-11 15/29 51.72 48/150 32 63/179 35.2 5-12 14/24 58.33 31/105 39.05 45/129 34.9 5-13 16/29 55.17 62/150 41.33 78/179 43.58 Private sector not included

Positioning and Attachment skills: The was an evident positive attitude of staff in all 4 governorates to assist mothers within the first 6 hours to breastfeed and show her the correct technique and show her how to express her mike if she becomes separated from her baby. However medical staff relied on nurses to do so and unfortunately many of the nurses showed the wrong technique of positioning at the breast as they described the technique used for bottle feeding.

There were little differences between the trained and hospitals not exposed to training and this could be attributed to the effect of the integration of IMCI training in those not exposed to BFHI and also integration of IMCI in university curricula of medical faculties of Egyptian universities. This shows that when these practices are properly integrated in the medica curricula, they result in a positive impact on the services provided by the graduated health professionals who later work in the health care system.

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Milk Expression: Most of the mothers did not confirm what the staff had reported especially with regards to being shown how to express their breastmilk and this was also confirmed by mothers with babies in special care unit.

This step covers the critical skills and techniques that need to be emphasized to every breastfeeding mother.

The study shows that there are pending needs in the following areas:

Information about how to breastfeed and how to express milk should be delivered during clinical rounds and ongoing patient bedside education in to the staff.

These important skills need to be taught during antenatal care to all pregnant women and not only to mothers after delivery or during postnatal check-ups, as this may be too late and negative consequences may have already set in.

The community plays an important role in disseminating these messages. Hence it is important to include these techniques in the messages given out not only to staff but also to mothers and their support system including close family member, support staff in primary health care, medical and nursing students and even schools students. Media could play an important role, but the messages need to be culturally sensitive and be presented in a way that does offend the public beliefs and traditions.

A very disappointing finding is the lack of proper implementation of the steps to maintain lactation in neonatal care units. We recommend that special protocols be prepared for these units and be integrated in their daily routines as essential practice.

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A Lactation specialist supports mother with 6 hours of birth in positioning her baby at her breast (above photo). She guides the mother who is bedded in with her baby, to feed in response to baby’s cues to readiness to feed (photo below).

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STEP 6

The step states that all health facilities serving with mothers and babies should: “Give newborn infants no food or drink other than breastmilk” This step is assessed by the following UNICEF/WHO Global Criteria: C6.1. Hospital data indicates that at least 75% of the full-term babies delivered in the past year were exclusively breastfed or fed expressed breastmilk from birth or discharge, or, if they received any feeds other than breastmilk this was because of documented medical reasons or mothers’ informed choices. C6.2. If the hospital has any clinical protocols or standards related to breastfeeding and infant feeding are they are in line with BFHI standards and evidence-based guidelines. C6.3. Materials which recommend feeding breastmilk substitutes, scheduled feeds or other inappropriate practices are not distributed to mothers C6.4. The hospital has an adequate facility/space and necessary equipment for giving demonstrations of how to prepare formula and other feeding options away from breastfeeding mothers. C6.5. If babies are prescribed any substitute it is based on acceptable medical reasons or informed choices for receiving something else. C6.6. If mothers have decided not to breastfeed, that the staff have discussed with them the various feeding options and were able to describe at least one thing that was discussed to help them decide what was suitable in their situations or said they didn’t want the information. C6.7. Mothers who were breastfeeding: the following reported that their babies had received only breastmilk or, if they had received anything else, it was for a justified reason. C6.8. Mothers of babies in neonatal care units have been informed of the importance of expressed breastmilk and hazards of supplements other than breastmilk to their babies C6.9. Health staff do not prescribe substitutes except for acceptable medical reasons. C6.10. Non clinical staff advise mothers of the importance of exclusive breastfeeding.

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Table (29) Distribution of the scores of Baby Friendly criteria for Step (6) according to the adapted BFHI global criteria in the Hospitals providing maternity services in hospitals of Sohag governorate: Criteria H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 Total Total of Step No % 6 C6-1 100 0 0 0 0 100 100 0 0 0 3 30

C6-2 0 0 0 0 0 0 0 0 0 0 0 0 C6-3 100 100 100 100 100 100 100 100 100 100 10 100 C6-4 100 100 100 100 100 100 100 0 100 0 8 80 C6-5 80 70 70 40 60 80 77 60 70 60 66/99 66.7 C6-6 0 0 0 0 0 50 66.7 100 0 100 6/8 75 C6-7 80 50 30 100 71.4 62 62.5 57 83.3 100 49/74 66.28 C6-8 0 0 0 66.7 0 0 22.2 50 0 22 7/23 30.4 C6-9 100 81 100 60 92 100 100 73.3 86 100 270/297 90.9 C6-10 100 100 90 74 70 100 83.3 78.13 55.6 83 227/283 80.2 H1: Sohag GH, H2: Tema DH, H3: Tahta DH, H4: Sakolta DH, H5:Baliana DH, H6: Akhmiem DH, H7: Sakolta DH, H8: Gehina DH, H9: Gerga DH, H10: Menshah DH Cut off of score for meeting step is 6.1: “Yes”, 6.2: “Yes” or doesn’t have protocols/standards, 6.3: Not distributed 6.4: “Yes”,6.5: 80%, 6.6: 8 80% on two items and 70% on other one

H1 100

H2 50 H9 H7 H3 0 H5 H3 H1 H4

H1: Sohag GH, H2: Tema DH, H3: Tahta DH, H4: Sakolta DH, H5:Baliana DH, H6: Akhmiem DH, H7: Sakolta DH, H8: Gehina DH, H9: Gerga DH, H10: Menshah DH Figure (19) Distribution of the scores of Baby Friendly criteria for Step (6) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Sohag governorate in Egypt.

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Table (30) Distribution of the scores of Baby Friendly criteria for Step (6) according to the adapted BFHI global criteria in the Hospitals providing maternity services in hospitals of Qaluibiya governorate: Criteria H1 H2 H3 H4 H5 H6 H7 H8 H9 Total Total of Step 6 No % C6-1 0 0 0 0 0 0 0 0 0 0 0 C6-2 0 0 0 0 100 100 100 0 0 3 33.3 C6-3 0 0 0 0 0 0 0 100 0 1 11.1 C6-4 100 0 0 0 100 100 0 0 0 3 33.3 C6-5 96 83 53 0 70 70 0 65 26 105/160 65.5 C6-6 0 0 0 0 50 13 0 0 0 14/60 23.3 C6-7 0 0 53 0 100 50 0 0 26 75/110 68.18 C6-8 0 0 40 0 100 0 0 0 0 24/32 75 C6-9 100 100 73 0 74 67 0 0 100 182/228 87.5 C6-10 1000 100 80 0 0 0 0 0 100 50/152 32.9 H1: Kafr shokr, H2: Toukh, H3: Shebin ElQanater, H4: Qanater ElKharaya, H5: ElKhanka, H6: Qaluib, H7: Shobra Shark, H*: Benha Specialty Pediatric Hospital, H9: Benha University Hospital Cut off of score for meeting step is 6.1: “Yes”, 6.2: “Yes” or doesn’t have protocols/standards, 6.3: Not distributed 6.4: “Yes”,6.5: 80%, 6.6: 8 80% on two items and 70% on other one

C1 100 C2 80 C3 60 C4 40 C9 C5 20 C7 C5 C6 0 C3 C7 H1 H2 H3 C1 H4 H5 C8 H6 H7 H8 H9

Figure (20) Distribution of the scores of Baby Friendly criteria for Step (6) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Qaluibiya governorate in Egypt

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Table (31) Distribution of the scores of Baby Friendly criteria for Step (6) according to the adapted BFHI global criteria in the Hospitals providing maternity services in hospitals of Alexandria governorate: Criteria H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 Total of Step % 6 C6-1 0 100 100 0 100 0 0 0 0 0 3 30

C6-2 100 100 0 0 100 0 100 0 0 0 4 40 C6-3 100 100 100 100 100 100 100 100 100 0 9 90 C6-4 100 100 100 100 100 100 100 100 100 0 9 90 C6-5 100 100 25 0 100 0 100 100 0 0 64/87 45.4 C6-6 0 0 0 0 0 0 0 0 0 0 0 0 C6-7 100 100 30 33.3 100 0 100 100 19 0 66/99 68 C6-8 0 0 10 0 100 0 50 50 33.3 0 13/52 24.9 C6-9 81 35 0 0 41.7 70 96 96 0 0 83/121 64.7 C6-10 100 0 0 0 14.3 50 75 75 0 100 22/40 57.1 H1: AboKeer Hospital, H2: Agamy Hospital, H3: Anfoushi Pediatric Hospital (mothers delivered in Shatby University or private), H4: Borg ElArab Hospital, H5: Dar Ismail Maternity Hospital, H6: Fawzi Moaz Pediatric Hospital, H7: ElAmria Hospital, H8: Ras El ElTin Hospital, H9: Raml Pediatric Hospital, H10: Goumhuria Hospital Cut off of score for meeting step is 6.1: “Yes”, 6.2: “Yes” or doesn’t have protocols/standards, 6.3: Not distributed 6.4: “Yes”,6.5: 80%, 6.6: 8 80% on two items and 70% on other one

100

80 C5 60 C7 40 C8 20 C10C9 0 C8 C10 H1 H2 H3 H4 H5 H6 C5 H7 H8 H9 H10

Figure (21) Distribution of the scores of Baby Friendly criteria for Step (6) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Alexandria governorate in Egypt.

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Table (32) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (6) for the 33 hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt:

Criteria Alex (10) Gharbia (4) Qaluibiya (9) Sohag (10) Total (33) of Step No. % No. % No. % No. % No. % 5 C6-1 3 30 4 100 0 0 3 30 13 39.3 C6-2 3 30 3 75 3 33.3 0 0 6 18.2 C6-3 8 80 3 75 1 11.1 10 100 24 72.7 C6-4 7 70 4 100 3 33.3 8 80 21 63.6 C6-5 83/183 45.4 20/24 83.3 105/160 65.5 66/ 99 66.7 274/466 58.8 C6-6 0 0 11/11 100 14/60 23.3 6/8 75 31/ 79 39.2 C6-7 70/104 68.3 10/10 100 75/110 68.18 49/74 66.2 204/298 68.5 C6-8 13/53 24.5 8/12 66.7 24/32 75 7/23 30.4 52/120 43.3 C6-9 90/139 64.7 89/89 100 182/228 87.5 270/279 90.9 631/735 85.8 C6-10 24/42 57.1 10/10 100 50/152 32.9 227/283 80.2 311/487 63.9

100

80

60

40 SG 20 QAL 0 GHB C6.1 ALX C6.2 C6.3 C6.4

Figure (22) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (6) with regards to policies, registries and protocols (clinical guidelines) for hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates.

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100 80 60 45 40 20 SG 0 QAL GHB C6.5 C6.6 ALX C6.7 C6.8 C6.9 ALX GHB QAL SG C6.10

Figure (23) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (6) as reported by clinical staff and mothers and observed in hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates.

Table (33) Comparison of the scores of Baby Friendly (BFHI) global criteria for Step (6) for the 31 public hospitals providing maternity and neonatal services by exposure to training: Criteria of Step Trained Hospitals Not trained Total Hospitals (31) 6 (7) Hospitals (24) No. % No. % No. % C6-1 5 71.43 8 33.3 13 41.9 C6-2 4 57.14 3 12.5 7 22.58 C6-3 7 100 19 79.17 26 83.87 C6-4 5 71.4 17 70.8 22 38.7 C6-5 80/88 90.9 154/232 66.38 234/320 73.125 C6-6 11/11 100 20/58 34.5 31/69 44.9 C6-7 38/42 90.48 86/136 63.2 124/178 69.66 C6-8 12/16 75 21/43 48.84 33/59 55.9 C6-9 158/173 91.3 428/504 84.9 586/677 86.56 C6-10 51/64 79.69 230/313 73.48 281/377 74.54

The criteria for making a hospital Baby friendly for step (6) were found incoherent with the requirements for Baby Friendly in the hospitals not exposed to the training as shown in table (33). Training made significant differences in the implementation of criteria 1- to 7 but not for 9 and 10. The former relates to the inability of the staff to relate to the acceptable medical reasons for prescribing substitutes. While C10

Page 69 MCH/MoHP-MCFC-UNICEF BFHI Muti-Center Needs Assessment Survey, 2016 indicates that the non-clinical staff was poorly informed about this critical step. Non-clinical staff are usually very close to the mother and are the ones that bring her the supplements when she is too tired to breastfeed rather than assisting her to breastfeed.

Hospitals need to be equipped with the following: 1- An area for teaching the non-breastfeeding mothers alternative feeding substitutes and how to prepare them. 2- The list of acceptable medical indications for giving substitutes. 3- The list of the hazards of feeding artificial formula or cow based milk 4- The space and facilities’ to teach mothers the importance of exclusive breastfeeding and the means of encouraging expressed breastmilk as the safest substitute for mothers who are away from their babies. 5- The equipment and facilities for storing expressed breastmilk 6- The informational material that can be used as reference for medical staff and for education to mothers about the importance of exclusive breastfeeding and how to choose safe alternatives for feeding infants when mothers are away or sick or unable to be with their babies.

BFHI Planning Workshop with Qaluibiya Health Directorate (2015): Director of District health office of Qanater Khairiya present BFHI plans to the MCH-MoH Qaluibiya Health Directorate director

Page 70 MCH/MoHP-MCFC-UNICEF BFHI Muti-Center Needs Assessment Survey, 2016

STEP 7, 8 & 9

These steps state that all health facilities serving with mothers and babies should:

“Step 7: Practice rooming-in – allow mothers and infants to remain together – 24 hours a day”

This step is assessed by the following UNICEF/WHO Global: C7.1.Observations in the postpartum wards and rooms and any well baby observation areas showed that the babies and mothers are rooming-in or, if not, had justifiable reasons for not being together. C7.2. Mothers interviewed when in the postpartum ward report that their babies have stayed with them since delivery or, if not, there were justifiable reasons.

In this survey we added three additional optional criteria as follows: C7.3. Mothers in the neonatal care units (NCU) are encouraged to spend as much time as possible with their babies and to hold their babies skin-to-skin (giving Kangaroo mother care). C7.4. Mothers who are working in these facilities are given space to breastfeed their babies or have their babies close to them while at work to continue to breastfeed. C7.5. Mothers who are visiting their babies in the NCU are provided a private space where they can express their milk.

Step 8: Encourage breastfeeding on demand This step is assessed by the following criteria: C8.1. Mothers interviewed when in the postpartum ward describe at least two things they were told about how to recognize if their babies were hungry. C8.2. Mothers interviewed when in the postpartum ward report that they had been advised to feed their babies for as often and as long as the babies wanted.

Step 9: Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. This step is assessed by the following criteria: C9.1. Breastfeeding babies observed in any area where babies and mothers are seen, these babies were not using bottles and teats or, if they were, their mothers had been informed of the risks. C9.2. Breastfeeding mothers report that their babies were not fed any fluids in bottles with teats. C9.2. Breastfeeding mothers report that their babies have not sucked on pacifiers

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Table (34) Distribution of the scores of Baby Friendly criteria for Steps 7, 8 and 9 according to the adapted BFHI global criteria in the Hospitals providing maternity services in Sohag governorate: Criteria H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 Total of Step No % 7 C7-1 56 53.8 47.8 36 52.2 57 55.6 51.85 54.2 46.15 133/259 51.35

C7-2 80 87 80 75 71.4 50 50 100 100 100 63/75 84 C7-3 50 60 60 50 10 60 44.4 50 40 44.4 48/118 40.67 C7-4 0 0 0 0 100 0 0 0 0 0 1/10 10

C7-5 100 100 100 100 100 100 100 100 100 100 10/10 100 C8-1 80 87 30 25 42.8 87 50 50 33.3 57.14 24/76 31.58 C8-2 65 80 62.5 75 64.7 82.3 84.2 80 73.3 62.5 132/180 73.3 C9-1 65 80 62.5 75 64.7 82.3 84.2 80 73.3 62.5 132/180 73.3 C9-2 80 62 80 75 71.4 87.5 62.5 71 83.3 85.7 57/75 76 C9-3 80 75 80 75 71.4 87.5 87.5 85 100 100 63/75 84  H1: Sohag GH, H2: Tema DH, H3: Tahta DH, H4: Sakolta DH, H5:Baliana DH, H6: Akhmiem DH, H7: Sakolta DH, H8: Gehina DH, H9: Gerga DH, H10: Menshah DH  Cut off of score for meeting criteria C7-1 & C7- 2 is 80%, cut off of score for meeting criteria C8-1 & C8-2 is 80%, cut off of score for meeting criteria C9- 1, C9-2, C9-3-3 is 80%.

100

50

C7.5 0 C7.4 C7.3 h1 h2 C7.2 h3 h4 h5 h6 C7.1 h7 h8 h9 h10

10H1: Sohag GH, H2: Tema DH, H3: Tahta DH, H4: Sakolta DH, H5:Baliana DH, H6: Akhmiem DH, H7: Sakolta DH, H8: Gehina DH, H9: Gerga DH, H10: Menshah DH Figure (24) Distribution of the scores of Baby Friendly criteria for Step (7) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Sohag governorate.

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100

50

0 H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 C8.1 C8.2

10H1: Sohag GH, H2: Tema DH, H3: Tahta DH, H4: Sakolta DH, H5:Baliana DH, H6: Akhmiem DH, H7: Sakolta DH, H8: Gehina DH, H9: Gerga DH, H10: Menshah DH

Figure (25) Distribution of the scores of Baby Friendly criteria for Step (8) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Sohag governorate in Egypt.

100

50

0 C9.3 H1 H2 H3 H4 H5 H6 C9.1 H7 H8 C9.1 C9.2 C9.3 H9 H10

10H1: Sohag GH, H2: Tema DH, H3: Tahta DH, H4: Sakolta DH, H5:Baliana DH, H6: Akhmiem DH, H7: Sakolta DH, H8: Gehina DH, H9: Gerga DH, H10: Menshah DH Figure (26) Distribution of the scores of Baby Friendly criteria for Step (9) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Sohag governorate.

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Table (35) Distribution of the scores of Baby Friendly criteria for Step (7, 8 and 9) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Qaluibiya governorate: Criteria H1 H2 H3 H4 H5 H6 H7 H8 H9 Total Total of Step 7 No % in % C7-1 86 66 64 0 72.5 100 0 67 77.8 165/224 73.7 C7-2 83 80 95 0 77 50 100 100 96 165/200 82.5 C7-3 No No No No No No No 0 0 0/55 0 C7-4 No No No No No No No No No 0 0 C7-5 No No No No No No No Yes Yes 2 22.2 C8-1 40 30 30 0 33 27 100 0 23 65/210 30.9 C8-2 36 33 50 0 23 20 0 0 13 63/210 30 C9-1 32 8 39.4 0 65.7 100 83.3 44 38 100/254 39.4 C9-2 60 47 0 0 76.7 60 100 40 23 98/210 46.67 C9-3 50 56.7 63.3 0 33.3 43.3 100 60 76 119/210 56.6 H1: Kafr shokr, H2: Toukh, H3: Shebin ElQanater, H4: Qanater ElKharaya, H5: ElKhanka, H6: Qaluib, H7: Shobra Shark; H8: Benha Pediatric specialty Hospital (BENCH); H9: Benha University Hospital (BUH) Cut off score for meeting criteria C7-1 & C7- 2 is 80%, cut off score for meeting criteria C8-1 & C8-2 is 80%, cut off score for meeting criteria C9- 1, C9-2, C9-3-3 is 80%.

100 80 C7-1 60 C7-2 40 C7-3 20 C7-5 C7-4 0 C7-3 C7-5 H1 H2 H3 H4 H5 C7-1 H6 H7 H8 H9

H1: Kafr shokr, H2: Toukh, H3: Shebin ElQanater, H4: Qanater ElKharaya, H5: ElKhanka, H6: Qaluib, H7: Shobra Shark

Figure (27) Distribution of the scores of Baby Friendly criteria for Step (7) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Qaluibiya governorate.

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100

50

0 H1 H2 H3 H4 H5 H6 H7 H8 H9 C8-1 C8-2

H1: Kafr shokr, H2: Toukh, H3: Shebin ElQanater, H4: Qanater ElKharaya, H5: ElKhanka, H6: Qaluib, H7: Shobra Shark Figure (28) Distribution of the scores of Baby Friendly criteria for Step (8) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Qaluibiya governorate.

100 80

60 C9-1 40 C9-2 20 C9-3 0 H1 H2 H3 H4 H5 H6 H7 H8 H9

H1: Kafr shokr, H2: Toukh, H3: Shebin ElQanater, H4: Qanater ElKharaya, H5: ElKhanka, H6: Qaluib, H7: Shobra Shark

Figure (29) Distribution of the scores of Baby Friendly criteria for Step (9) according to the adapted BFHI global criteria in the hospitals providing maternity services in Qaluibiya governorate.

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Table (36) Distribution of the scores of Baby Friendly criteria for Step (7, 8 and 9) according to the adapted BFHI global criteria in the hospitals providing maternity services in Alexandria governorate: Cr. H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 Total Total Step # % 7 C7-1 29.2 100 25 0 25 20 87.5 75 100 10 41/110 37.3 C7-2 100 100 16.7 67 100 0 100 100 0 100 53/64 72 C7-3 100 0 0 33 100 0 100 100 0 0 21/27 77.8 C7-4 No No Yes No No No No No No No 1 10 C7-5 No No Yes No No Yes Yes Yes No No 4 40 C8-1 100 0 30 0 30.4 0 25 25 0 67 90/90 100 C8-2 100 0 50 100 45.8 20 100 100 0 67 60/91 65.9 C9-1 96.5 100 0 50 100 30 33.3 100 17.1 76.7 125/ 66.5 198 C9-2 100 100 55.5 0 100 0 100 100 23 44.4 73/ 52.9 107 C9-3 75 100 55.5 100 100 30 100 100 25 67 59/ 86 46.26

H1: AboKeer Hospital, H2: Agamy Hospital, H3: Anfoushi Pediatric Hospital (mothers delivered in Shatby University or private), H4: Borg ElArab Hospital, H5: Dar Ismail Maternity Hospital, H6: Fawzi Moaz Pediatric Hospital, H7: ElAmria Hospital, H8: Ras El ElTin Hospital, H9: Raml Pediatric Hospital, H10: Goumhuria Hospital Cut off score for meeting criteria C7-1 & C7- 2 is 80%, cut off score for meeting criteria C8-1 & C8-2 is 80%, cut off score for meeting criteria C9- 1, C9-2, C9-3-3 is 80%.

100

80 C7-1 60 C7-2 40 C7-3 20 C7-4 C7-5 0 C7-5 C7-3 H1 H2 H3 H4 H5 H6 C7-1 H7 H8 H9 H10

Figure (30) Distribution of the scores of Baby Friendly criteria for Step (7) according to the adapted BFHI global criteria in the hospitals providing maternity and neonatal services in Alexandria governorate in Egypt.

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100

50

0 H1 H2 H3 H4 H5 H6 H7 H8 H9 C8-1 C8-2 H10

Figure (31) Distribution of the scores of Baby Friendly criteria for Step (8) according to the adapted BFHI global criteria in hospitals providing maternity and neonatal services in Alexandria governorate in Egypt.

100

50 C9-1 C9-2 0 C9-3 H1 H2 H3 H4 H5 H6 H7 H8 H9 H10

Figure (32) Distribution of the scores of Baby Friendly criteria for Step (9) according to the adapted BFHI global criteria in the hospitals providing maternity and neonatal services in Alexandria governorate in Egypt.

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The lowest criterion in Step (7) was that related to rooming-in mothers with babies admitted to neonatal intensive care as shown in the table and figures below. It was highest in the hospitals of Gharbia that were exposed to training. In Step 8 mothers reported they were not taught infant feeding cues whether during the first hour of STS (as this was not implemented in most hospitals or in the ward. In Step 9, bottles and pacifiers were mostly offered in the private sector.

Table (37) Comparison of the scores of Baby Friendly criteria for Step (7, 8 and 9) according to the adapted BFHI global criteria in the Hospitals providing maternity services in hospitals of Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt: Alexandria Gharbia Qaluibiya Sohag Total (10) (4) (9) (10) (33) No % No % no % no % no % C7-1 75/129 58.1 24/28 85.7 165/224 73.7 133/259 51.35 397/640 62.03 C7-2 116/161 72 18/18 100 165/200 82.5 63/75 84 362/407 88.9

C7-3 27/53 34.1 8/12 66.7 0/55 0 48/118 40.67 83/238 34.9 C7-4 9 90 0 0 0 0 0 0 9/33 27.2 C7-5 6 60 4 100 2 22.2 9 90 21/33 63.6 C8-1 90/204 50.3 20/22 90.9 65/210 30.9 43/76 56.57 218/512 42.6 C8-2 95/205 45 25/29 86.2 63/210 30 24/76 31.58 207/520 39.8 C9-1 137/206 66.5 31/31 100 100/254 39.4 132/180 73.3 400/671 59.6 C9-2 100/193 52.9 25/25 100 98/210 46.67 57/75 75 280/503 55.7 C9-3 85/172 46.26 25/25 100 119/210 56.6 63/75 84 292/482 60.6

100 80 60 40 C7-5 C7-4 20 C7-3 0 C7-2 ALX C7-1 GRB QAL SG

Figure (33) Comparison of the scores of Baby Friendly criteria for Step (7) according to the adapted BFHI global criteria in the Hospitals providing maternity services in hospitals of Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt.

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100

80

60

40

20

0 C8-2 ALX C8-1 GRB QAL SG

Figure (34) Comparison of the scores of Baby Friendly criteria for Step (8) according to the adapted BFHI global criteria in hospitals providing maternity services in hospitals of Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt.

100

50 C9-3 0 C9-2 ALX C9-1 GRB QAL SG

Figure (35) Comparison of the scores of Baby Friendly criteria for Step (9) according to the BFHI global criteria in hospitals providing maternity services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt.

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Hospitals that were trained scored higher in all practices but there were no differences with regards to instructions and guidance to mothers on how to feed to infant cues and not to baby’s cry.

Table (38) Comparison of the scores of Baby Friendly criteria for Step (7) according to the adapted BFHI global criteria in the Hospitals by exposure t training:

Criteria of Step Score for Trained Score for Not- Score for total 7 (7) Trained (24) (31) no % no % no % 7-1 83/104 79.8 200/348 57.5 283/452 62.6 7-2 74/80 92.5 139/179 77.65 213/259 82.2 7-3 18/29 62.07 42/138 30.4 60/167 35.9 7-4 0 0 1 4.2 1 3.2 7-5 5 71.4 12 50 17 54.8 C8-1 46/83 55.4 129/266 48.5 175/349 50.1 C8-2 54/91 59.3 180/373 48.3 234/464 50.4 C9-1 82/97 84.5 255/455 56.04 337/552 61.05 C9-2 72/87 83.7 164/288 56.94 236/375 62.9 C9-3 70/87 80.46 153/243 62.9 223/330 67.58

These three steps are grouped together here because they depend solely on mother responses not to the administrative or the clinical or non-clinical staff, but directly reflect what staff are doing to guide this mother in their practices and how they are influencing these practices.

Rooming-in for mothers in postnatal ward was high in most of the hospitals with little differences between governorates. However rooming-in the mother with the baby in the NCU was very low. Mothers were allowed to come and see or breastfeed in most cases but restricted to stay with their baby for very long periods over the day or night.

On-demand or rather the cue feeding was particularly defective in all hospitals. Teaching mothers infant feeding cues while baby was performing skin-to-skin (STS) was defective because STS for one hour was not practiced by most hospitals. While instructing mothers to feed to the cue and not placing any restrictions on the

Page 80 MCH/MoHP-MCFC-UNICEF BFHI Muti-Center Needs Assessment Survey, 2016 feed was defective in the sense that no instructions were given to the mother whether to feed on the cue or to the clock. The prevailing misconception, that “babies should be fed only when baby cries”, is still prevalent. The source of this information was conveyed to them usually by their accompanying family member.

Prohibiting the use of bottles and pacifiers was highest in Gharbia and Sohag and lowest in Qaluibiya and Alexandria. This is because in the latter two regions we included many of the private hospitals, so this mostly reflects private hospital practices and especially NCU practices where the bottle was used to feed the preterm rather than the cup. The implementation of this step was ideal in Gharbia as they were taught in their training to practically do the cup feeding and the staff of the NCU were cooperative in accepting and implementing it.

Recommendations

The following is recommended by hospital area: In the Obstetric wards: 1- Illustrative material should be displayed (in poster or handout form) showing mothers where and how to place her baby in the bed or in a cot nearby her; and the benefits explained. While the wrong practice of having the baby placed at the end of the bed or carried by a relative or take away from her should be crossed and the consequences made clear to her. Both should be placed in the poster or handout so that mothers are aware of what is right and what is wrong. This material should also be placed close to the nursing staff station so they are reminded to include it in their treatment and patient care plan. 2- To the cue versus feeding when the baby cries should be also clarified as right and wrong. The signs of the baby’s readiness to feed should be made clear. The benefits of cue feeding versus feeding by the clock or feeding only when baby cries should again be clarified to the mother. 3- The alternatives to feeding and soothing babies should be made clear when displaying posters that guide mothers not to use bottles or pacifiers. Bottles and teats are for formula feeding mothers, therefore prohibiting their use may not be ideal. We need to prohibit their use for the babies who are breastfeeding or be breastfeeding and the benefits of using an alternative feeding method and hazards of not should be also made clear to mothers and to staff. In the neonatal care units and pediatric wards: 1- Hospital policies need to encourage mothers to be with their babies inside the NCU wards to care for their baby even if they need to wear special clothing. The benefits of this policy on reducing cross infection,

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increased turn over and minimizing complication and hospital stay and thereby reducing the costs and wasted resources. 2- Kangaroo mother care should be routinely encouraged and the concept taught and practiced by the mother before discharge so she can practice it when she goes back home. 3- Neonatal care unit feeding policies for encouraging feeding expressed breastmilk, for babies unable to feed directly at the breast, should be changed to cup feeding by enforcing policies and training staff to use cup instead of a bottle with a teat. 4- In pediatric wards, protocols/flow charts should be made available to teach and guide staff how to assist mothers who are admitted with bottle fed baby who is less than 12 months to be encouraged to suckle at the breast and for the mother to relactate if her milk has dried up and to feed by cup until she can gradually stop giving the other milks.

In the outpatient pediatric department (OPD) 1- Intensify the display of educational material and audiovisuals that can be used to convey to mothers how to increase her milk supply by on- demand feeding and how to sooth the fussy baby by cuddling and STS rather than use of pacifiers. 2- Instructing physicians in OPD to integrate exclusive breastfeeding practices in their prescription to mothers: many of the mothers attending OPD are coming for simple common illnesses that are directly linked to the mother giving decoctions by bottle (or giving the night bottle feed) or offering baby pacifiers, hence it is important to have the attending physicians bring mother’s attention that these practices should be stopped as part of any treatment they are prescribing to the baby. 3- Cross cutting programs such as IMCI and EPI can also be directed to include these messages in their service areas and in their instructions to care takers.

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STEP 10

The step states that all health facilities serving with mothers and babies should: “Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.”

This step is assessed by the following UNICEF/WHO global criteria: C10.1. Mothers are given information concerning where they can get support if they need help with feeding their babies after return home and mentions at least one source of information. C10.2. The facility works to either foster the establishment of or coordinate with mother support groups and other community services that provide breastfeeding/ infant feeding support to mothers and can describe an adequate way in which this is done. C10.3. The staff encourages mothers and their babies to be seen soon after discharge at the facility or in the community by a skilled breastfeeding support person who can assess feeding and give any support needed, and can describe an appropriate referral and adequate timing for the visits. C10.4. Printed information is distributed to mothers before discharge, if appropriate, on how and where mothers can find help on feeding their babies after return home and includes information on at least one type of help available. C10.5. Mothers report that they have been given information on how and where to get help with feeding their babies after return home and can mention one type of help available.

Table (39) Distribution of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in the Hospitals providing maternity services in hospitals of Sohag governorate: Hospital H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 Total Criteria No. % C10-1 100 0 100 10 100 100 100 100 100 100 9/10 90 0 C10-2 100 100 0 0 0 0 0 0 0 0 2/10 20 C10-3 100 100 0 0 100 100 100 100 100 100 8/10 80 C10-4 0 100 0 0 0 0 0 0 0 0 1/10 10 C10-5 90 87 30 24 57 75 37 57 50 42.8 42/75 56 H1: Sohag GH, H2: Tema DH, H3: Tahta DH, H4: Sakolta DH, H5:Baliana DH, H6: Akhmiem DH, H7: Sakolta DH, H8: Gehina DH, H9: Gerga DH, H10: Menshah DH Cut off of score for meeting STEP 1-3: C1-3 “Yes” for 2 out of the 3 items; 10.4: “Yes”, or not appropriate

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100

80 C10-1 60 C10-2 40 C10-3 20 C10-4 c10.5 0 H1 H2 H3 H4 H5 H6 H7 H8 H9 H10

10H1: Sohag GH, H2: Tema DH, H3: Tahta DH, H4: Sakolta DH, H5:Baliana DH, H6: Akhmiem DH, H7: Sakolta DH, H8: Gehina DH, H9: Gerga DH, H10: Menshah DH Figure (36) Distribution of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in hospitals providing maternity services in hospitals of Sohag governorate. Table (40) Distribution of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Qaluibiya governorate: Criteria H1 H2 H3 H4 H5 H6 H7 H8 H9 Total Total of Step 10 No % C10-1 0 0 0 0 0 0 0 0 0 0 0 C10-2 0 0 0 0 0 0 0 0 0 0 0 C10-3 0 0 0 0 0 0 0 0 0 0 0 C10-4 0 0 0 0 0 0 0 0 0 0 0 C10-5 33 23 63 0 0 20 100 0 0 52/210 24.8 H1: Kafr shokr, H2: Toukh, H3: Shebin ElQanater, H4: Qanater ElKharaya, H5: ElKhanka, H6: Qaluib, H7: Shobra Shark, H8: Benha Specialty Hospital, H9: Benha University Hospital Cut off of score for meeting STEP 1-3: C1-3 “Yes” for 2 out of the 3 items; 10.4: “Yes”, or not appropriate

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100

80 C10-1 60 C10-2 40 C10-3

20 C10-4 C10-5 0 C10-4 H1 H2 H3 H4 H5 C10-1 H6 H7 H8 H9

Figure (37) Distribution of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in hospitals providing maternity services in Qaluibiya governorate.

Table (41) Distribution of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in the Hospitals providing maternity services in Alexandria governorate:

Criteria H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 Total Total of Step No % 10 10-1 100 0 0 0 100 0 0 0 100 0 3 30 10-2 100 0 0 0 100 0 0 0 0 0 2 20 10-3 100 0 0 0 100 0 0 0 0 0 2 20 10-4 0 0 0 0 100 100 100 100 0 0 4 40 10-5 100 0 0 0 0 0 0 100 6 11 31/ 11 106 H1: AboKeer Hospital, H2: Agamy Hospital, H3: Anfoushi Pediatric Hospital (mothers delivered in Shatby University or private), H4: Borg ElArab Hospital, H5: Dar Ismail Maternity Hospital, H6: Fawzi Moaz Pediatric Hospital, H7: ElAmria Hospital, H8: Ras El ElTin Hospital, H9: Raml Pediatric Hospital, H10: Goumhuria Hospital Cut off of score for meeting STEP 1-3: C1-3 “Yes” for 2 out of the 3 items; 10.4: “Yes”, or not appropriate

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100 80 60 40 20 C10-5 0 C10-4 C10-3 H1 H2 H3 C-10-2 H4 H5 H6 H7 C10-1 H8 H9 H10

Figure (38) Distribution of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in the hospitals providing maternity services in Alexandria governorate.

In all the hospitals in all the governorates they did not foster the establishment of or coordinate with mother support groups (C2) and no printed matter was given to the mother (C4). This was highest in the hospitals of Gharbia that were exposed to training.

Table (42) Comparison of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in the hospitals providing maternity services in Alexandria, Gharbia, Qaluibiya and Sohag governorates:

Criteria Alexandria Gharbia Qaluibiya Sohag Total of Step (10) (4) (9) (10) (33) 10 No. % No. % No. % No. % No. % C10-1 3 30 3 75 0 0 9 90 15 45.5 C10-2 2 20 2 50 0 0 2 20 6 18.2 C10-3 2 20 3 75 0 0 8 80 13 39.4 C10-4 3 30 1 25 0 0 1 10 5 15.2 C10-5 31/126 24.6 24/24 100 52/210 24.8 42/75 56 149/435 34.25

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100

80

60

40 C10.5 C10.4 20 C10.3 0 C10.2 ALX C10.1 GRB QAL SG

Figure (39) Comparison of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in the hospitals providing maternity services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt.

The following table displays the differences between the hospitals exposed to training and those not exposed to training in relation to the global criteria of BFHI for this step:

Table (43) Comparison of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in the hospitals providing maternity services by exposure to training: Score for Trained Not Trained Total Criteria of (7) (24) (31) Step 10 No. % No. % No. % C10-1 5 71.4 10 41.67 15 48.39 C10-2 4 57.14 2 8.33 6 19.35 C10-3 5 71.4 8 33.3 13 41.94 C10-4 3 42.85 3 12.5 6 19.35 C10-5 41/86 47.67 100/271 36.9 141/357 39.5

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80

60

40 Trained 20 Series 2

0 Series 2 C10-1 C10-2 Trained C10-3 C10-4 C10-5

Figure (40) Comparison of the scores of Baby Friendly criteria for Step (10) according to the adapted BFHI global criteria in the hospitals providing maternity services by exposure to training.

This is a step that is usually very difficult to achieve since there is no direct link between the hospitals and the community unless the community is allowed to participate in the hospital activities or is part of the system that allows it to be integrated in the hospital services. Some hospitals have follow-up clinics but these are few and because the mother lives in faraway villages it is usually easier for her to go to the local clinic in her area.

In most of the hospitals responded that they did not “foster the establishment of or coordinate with mother support groups and other community services”. Also printed information, on how and where mothers can find help on feeding their babies after return home is not distributed to mothers before discharge. Only 1 in 4 mothers in governorates of Alexandria, Sohag and Qaluibiya reported that they were given this information, while in the recently trained hospitals in Gharbia confirmed they were informed, but the written or printed matter was not available.

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1- Encourage hospitals to foster the establishment of or coordinate with mother support groups and other community services or primary health care centers in the region where the mother lives. 2- Print information for mothers on how and where mothers she can find help on feeding their babies after they return home and distribute to mothers before discharge. 3- Encourage trained woman village leaders (Raedat) to leave a list of their contacts in the maternity wards of hospitals in the region so that mothers can contact them when they go back home whenever they need advice or help with breastfeeding.

BFHI Planning workshop with Alexandria Health Directorate (2015)

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MOTHER FRIENDLY

This is assessed by the following criteria:

MF.1. Interview with head/director of maternity services. The head of maternity services reports that a written hospital policy require mother/baby friendly labour and birthing practices, including:

 Encouraging women to have companions of their choice to provide physical and/or emotional support throughout labour and birth.  Allowing women to drink and eat light foods during labour, if desired.  Encouraging women to consider the use of non-drug methods of pain relief unless analgesic or anesthetic drugs are necessary because of complications, respecting the personal preferences of the women.  Encouraging women to walk and move about during labour, if desired, and assume positions of their choice while giving birth, unless a restriction is specifically required for a complication and the reason is explained to the mother.  Care that does not involve invasive procedures such as rupture of the membranes, episiotomies, acceleration or induction of labour, instrumental deliveries or caesarean sections, unless specifically required for a complication and the reason is explained to the mother. MF.2. Interviews with clinical staff reveal that they can describe at least two recommended practices that can help mothers be more comfortable and in control during labour and birth MF.3. Interviews with clinical staff reveal that they can list at least three labour and birthing procedures that should not be used routinely but only if required due to complications. MF.4. Interviews with clinical staff reveal that they can describe at least two labour and birthing practices that make it more likely that breastfeeding get off to a good start. MF.5. Interviews with pregnant women show that they were told by the staff that women could have companions of their choice with them throughout labour and birth and were given at least one reason it might be helpful. MF.6. Interviews with pregnant women show that they were told by the staff about ways to deal with pain and be more comfortable during labour and what is better for mothers, babies, and breastfeeding.

Scoring: For this step on mother-friendly care to be fully implemented, the following responses are the minimum required: MF 1: “Yes” for 4 out of 5 topics MF 2-4: 80% on two of the items and 50% on the other one MF 5-6: 70% on one of the items and 50% on the other one

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Table (44) Distribution of the scores of Baby Friendly criteria for becoming Mother Friendly according to the BFHI global criteria in the Hospitals providing maternity services in Sohag governorate: Criteria H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 Total of MF # % MF-1 100 100 0 100 0 100 100 0 100 0 6/10 60 MF-2 81 53 0 53 85.7 75 28.6 38.9 40 67 89/159 56 MF-3 90 69 0 60 71.4 79 57 83.3 52 88.9 113/159 71.07 MF-4 81 53 0 47 85.7 70 28.6 72.2 32 72.2 92/159 57.86 MF: Mother Friendly; 10H1: Sohag GH, H2: Tema DH, H3: Tahta DH, H4: Sakolta DH, H5:Baliana DH, H6: Akhmiem DH, H7: Sakolta DH, H8: Gehina DH, H9: Gerga DH, H10: Menshah DH

100

80

60

40

20

0 MF-4 MF-3 H1 H2 MF-2 H3 H4 H5 H6 MF-1 H7 H8 H9 H10

Figure (41) Distribution of the scores of Baby Friendly criteria for becoming Mother Friendly according to the BFHI global criteria in the Hospitals providing maternity services in Sohag governorate.

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Table (45) Distribution of the scores of Baby Friendly criteria for becoming Mother Friendly according to the BFHI global criteria in the Hospitals providing maternity services in hospitals of Qaluibiya governorate: Criteria of MF H1 H2 H3 H4 H5 H6 H7 H8 H9 Total % MF-1 40 0 100 0 100 0 0 - 0 2 22.22 MF-2 20 2 16 0 40 16.7 100 20 53 61/232 26.3 MF-3 20 2 23 0 43 23.3 62.5 0 47 63/226 27.9 MF-4 16 2 40 0 50 13.3 100 0 12 58/226 25.7 MF: Mother Friendly , H1: KafrShokr, H2: Toukh, H3: Shebin ElQanater, H4: Qanater ElKharaya, H5: ElKhanka, H6: Qaluib, H7: Shobra Shark, H8: Benha Specialty Hospital, H9: Benha University Hospital

100

MF-1 50 MF-2 0 MF-4 MF-3 MF-3 H1 MF-2 H2 H3 MF-4 H4 H5 MF-1 H6 H7 H8 H9

Figure (42) The status of Baby Friendly criteria for Mother Friendly according to the BFHI global criteria in hospitals providing maternity services in Qaluibiya governorate. Table (46) Distribution of the scores of Baby Friendly criteria for becoming mother friendly according to the BFHI global criteria in the Hospitals providing maternity services in Alexandria: Criteria H1 H2 H3* H4 H5 H6* H7 H8 H9* H10 Total Total of Code No. % MF-1 0 0 0 0 100 0 0 0 0 0 1 10 MF-2 14.3 10 0 0 96 0 0 8/23 0 0 36/137 25.8 34.7 MF-3 33.3 0 0 0 100 0 0 7/23 0 7.7 39/137 27 30.4 MF-4 0 0 0 0 100 0 0 6/23 0 7.7 31/137 23.9 26.1 MF-5 NA NA NA NA NA NA NA NA NA NA NA NA MF-6 NA NA NA NA NA NA NA NA NA NA NA NA H1: AboKeer Hospital, H2: Agamy Hospital, H3: Anfoushi Pediatric Hospital (mothers delivered in Shatby University or private), H4: Borg ElArab Hospital, H5: Dar Ismail Maternity Hospital, H6: Fawzi Moaz Pediatric Hospital, H7: ElAmria Hospital, H8: Ras El ElTin Hospital, H9: Raml Pediatric Hospital, H10: Goumhuria Hospital.

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100

80

60 MF-1

40 MF-2 MF-3 20 MF-4 0 H1 H2 H3 H4 H5 H6 H7 H8 H9 H10

Figure (43) Distribution of the scores of Baby Friendly criteria for becoming Mother Friendly according to the BFHI global criteria in hospitals providing maternity services in Alexandria.

Mother friendly criteria were primarily not included in the hospital policies. Its implementation was highest in the trained hospitals in Gharbia.

Table (47) Comparison of the scores of Baby Friendly criteria for Mother Friendly according to the adapted BFHI global criteria in the hospitals providing maternity services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt: MF Alexandria Gharbia Qaluibiya Sohag Total Criteria (10) (4) (9) (10) (33) No. % No. % No. % No. % No. % MF-1 1 10 3 75 2 22.22 6 60 12 36.4 MF-2 40/155 25.8 76/ 118 64.4 61/232 26.3 89/ 159 56 266/664 40.4 MF-3 42/155 27.1 101/118 85.6 63/226 27.9 113/159 71.1 319/658 48.5 MF-4 37/155 23.9 101/118 85.6 58/226 25.7 92/159 57.9 288/658 43.8

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100

80

60

40 Sohag 20 Qal 0 Gharbia MF-1 Alex MF-2 MF-3 MF-4

Figure (44) Comparison of the scores of Baby Friendly criteria for Mother Friendly according to the adapted BFHI global criteria in hospitals providing maternity services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt.

Table (48) Comparison of the scores of Baby Friendly criteria for becoming Mother Friendly according to the adapted BFHI global criteria in the hospitals providing maternity services in by exposure to training:

Score for Criteria of Trained Not Trained Total Mother Friendly (MF) Hospitals (24) (31) (7) No. % No. % No. % MF1-1 5 71.4 7 29.1 12 38.7 MF1-2 5 71.4 7 29.1 12 38.7 MF1-3 5 71.4 6 25 11 35.5 MF1-4 6 85.7 6 25 12 38.7 MF1-5 6 85.7 7 29.1 13 41.9 MF2 112/ 60.5 134/ 32.29 246/ 41 185 415 600 MF3 140/ 75.7 157/ 37.8 297/ 49.5 185 415 600 MF4 137/ 74.05 140/ 33.7 277/ 46.17 185 415 600

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100 80 60 40 MF4 20 MF3 0 MF2 ALX MF1 GRB QAL SG

Figure (45) Comparison of the scores of Baby Friendly criteria for Mother Friendly according to the adapted BFHI global criteria in the hospitals providing maternity services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt.

N.B: Although these were pediatric hospitals but the mothers interviewed in these hospitals were reflecting their birth experiences in the private hospitals where they delivered their babies.

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COMPLIANCE TO THE CODE

This is assessed by the following UNICEF/WHO Global Criteria for the International Code of marketing of Breastmilk Substitutes and its subsequent resolutions:

Code 1: In compliance with the Code, no employees of manufacturers or distributors of breastmilk substitutes, bottle, teats or pacifiers have any direct or indirect contact with pregnant women or mothers. Code 2: In compliance with the Code, the hospital does not receive any free gifts from manufacturers or distributors of breastmilk substitutes, bottles, teats or pacifiers. Code 3: In compliance with the Code, pregnant women, mothers and their families are not given marketing materials, samples or gift packs by the facility that include breastmilk substitutes, bottles, pacifiers, other equipment for preparing feeds or coupons. Code 4: A review of records and receipts indicates that any breastmilk substitutes, including special formulas and other feeding supplies, are purchased by the health care facility for the wholesale price or more. Code 5: In compliance with the Code, no promotional materials for breastmilk substitutes, bottles, teats or dummies or any other designated products, as per national laws, are displayed or distributed to pregnant women, mothers or staff. Code 6: Infant formula cans and prepared bottles are kept out of view. Code 7: Staff can give two reasons why it is important not to give free formula samples from the infant formula companies to mothers (during an interview with those randomly selected from different departments of the facility).

Scoring: For Code compliance to be fully implemented, the following responses are the minimum required: Code 1: “Yes”, Code 2: “Yes”, Code 3: “Yes”, Code.4: “Yes”, Code 5: “Yes”, Code 6: “Yes” Must have a “Yes” to 5 out of 6 of the above items, including a “Yes” to items #3 and #4. Code 7: 80% The extent of fulfillment of the above criteria by the hospitals following are displayed in table (13-A) by governorate and table (13-B) by exposure to training:

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Table (49) Distribution of the scores of Baby Friendly criteria for compliance to the code according to the adapted BFHI global criteria in the Hospitals providing maternity services in Sohag governorate

Criteria H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 Total Total of Code % C1 100 100 0 100 100 100 100 0 100 100 8/10 80 C2 100 100 0 100 100 100 100 0 100 100 8/10 80 C3 100 100 0 100 100 100 100 0 100 100 8/10 80 C4 100 100 0 100 100 100 100 0 100 100 8/10 80 C5 100 100 0 100 100 100 100 0 100 100 8/10 80 C6 100 100 0 100 0 100 100 100 100 100 8/10 80 C7 in % 83.3 60 0 90 92.6 83 66 50 40 80 191/207 92.3 H1: Sohag GH, H2: Tema DH, H3: Tahta DH, H4: Sakolta DH, H5:Baliana DH, H6: Akhmiem DH, H7: Sakolta DH, H8: Gehina DH, H9: Gerga DH, H10: Menshah DH Criteria must have a “Yes” to 5 out of 6 of the above items, including a “Yes” to items #3 and #4and for criteria 7 is 80%

H1 100 H2 80 H3 60 H4 40 H10 H5 H7 20 H6 H4 0 H7 C1 C2 C3 H1 C4 C5 C6 C7 10H1: Sohag GH, H2: Tema DH, H3: Tahta DH, H4: Sakolta DH, H5:Baliana DH, H6: Akhmiem DH, H7: Sakolta DH, H8: Gehina DH, H9: Gerga DH, H10: Menshah DH

Figure (46) Distribution of the status of Baby Friendly criteria for Code compliance according to the BFHI global criteria in hospitals providing maternity services in Sohag governorate.

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Table (50) Distribution of the scores of Baby Friendly criteria for Code compliance according to the BFHI global criteria in the Hospitals providing maternity services in Qaluibiya governorate:

Criteria H1 H2 H3 H4 H5 H6 H7 H8 H9 Total Total of Code % C1 100 100 0 100 100 100 0 100 100 7/9 57.1 C2 100 0 0 100 100 0 0 0 0 3/9 42.85 C3 100 100 100 100 100 100 0 0 100 6/9 85.7 C4 0 0 0 0 0 0 0 0 0 0 0 C5 100 100 0 100 100 100 0 100 0 5/9 71.4 C6 0 0 0 0 100 100 0 0 0 2/9 28.57 C7 in % 96 80 73 53 73 67 100 100 100 198/261 75.8 H1: KafrShokr, H2: Toukh, H3: Shebin ElQanater, H4: Qanater ElKharaya, H5: ElKhanka, H6: Qaluib, H7: Shobra Shark, H8: Benha Specialty Hospital, H9: Benha University Hospital Must have a “Yes” to 5 out of 6 of the above items, including a “Yes” to items #3 and #4and for criteria 7 is 80%

100 C1 80 C2 60 C3

40 C4 C5 20 C7 C5 C6 0 C3 C7 H1 H2 H3 H4 H5 C1 H6 H7 H8 H9 Figure (47) Distribution of the scores of Baby Friendly criteria for Code compliance according to the BFHI global criteria in hospitals providing maternity services in Qaluibiya governorate.

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Table (51) Distribution of the scores of Baby Friendly criteria for Code compliance according to the BFHI global criteria in the Hospitals providing maternity services in hospitals of Alexandria governorate in Egypt:

Criteria H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 Total Total of Code No % C10-1 100 100 100 100 100 100 100 100 100 100 10 100 C10-2 100 100 100 100 100 100 100 100 100 100 10 100 C10-3 100 100 100 100 100 100 100 100 100 100 10 100 C10-4 0 0 0 0 0 0 0 0 0 0 0 0 C10-5 100 100 100 100 100 100 100 100 100 100 10 100 C10-6 100 100 100 100 100 100 100 100 100 100 10 100 C10-7 7/7 14/20 17/17 10/13 21/24 7/10 21/23 16/21 0/40 12/13 125/ 66.5 100 70 100 76.9 87.5 70 91.3 76.2 0 92 188 H1: AboKeer Hospital, H2: Agamy Hospital, H3: Anfoushi Pediatric Hospital (mothers delivered in Shatby University or private), H4: Borg ElArab Hospital, H5: Dar Ismail Maternity Hospital, H6: Fawzi Moaz Pediatric Hospital, H7: ElAmria Hospital, H8: Ras El ElTin Hospital, H9: Raml Pediatric Hospital, H10: Goumhuria Hospital Must have a “Yes” to 5 out of 6 of the above items, including a “Yes” to items #3 and #4and for criteria 7 is 80%

Table (52) Comparison of the scores of Baby Friendly criteria for Code compliance according to the BFHI global criteria in the Hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt:

Score for Alexandria Gharbia Qaluibiya Sohag Total Criteria of (10) (4) (9) (10) (33) Code No. No. No. % No. No. % % % % Code-1 8 80 4 100 7 57.1 8 80 27 81.8 Code-2 8 80 4 100 3 42.85 8 80 23 69.7 Code-3 7 70 4 100 6 85.7 8 80 25 75.6 Code-4 4 40 4 100 0 0 8 80 16 48.5 Code-5 7 70 4 100 5 71.4 8 80 24 72.7 Code-6 7 70 4 100 2 28.57 8 80 21 63.6 Code -7 94/ 63.1 109/91.6 198/75.8 191/92.3 592/ 80.4 149 119 261 207 736

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100 80 60 40 20 SG 0 QAL GRB Code 1 Code 2 Code 3 Code 4 ALX Code 5 Code 6 Code 7

Figure (48) Comparison of the scores of Baby Friendly criteria for Code compliance according to the BFHI global criteria in the Hospitals providing maternity and neonatal services in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt.

Table (53): Comparison of the scores of Baby Friendly criteria for Code compliance according to the BFHI global criteria in the Hospitals providing maternity and neonatal care by exposure to training:

Score for Criteria of Trained Not trained Total Code Hospitals (21) (28) (7) No. % No. No. % % Code-1 7 100 18 25 89.3 85.7 Code-2 7 100 16 23 82.14 76.19 Code-3 7 100 18 25 89.3 85.7 Code-4 3 42.8 12 15 53.57 57.1 Code-5 7 100 18 25 89.3 85.7 Code-6 2 28.57 18 20 71.4 85.7 Code -7 95/111 368/552 463/663 69.83 85.6 66.67

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100 80 60

40 Trained 20 Not trained 0 Code-1 Code-2 Code-3 Code-4 Code-5 Code-6 Code - 7

Figure (49) Comparison of the scores of Baby Friendly criteria for Code compliance according to the BFHI global criteria in hospitals providing maternity and neonatal care by exposure to training.

MCH/MoH representatives & specialists from UNICEF Cairo office participate in BFHI Planning Workshops in Alexandria: Plans are enthusiastically presented by hospital staff

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The maternal and child health centers (MCH) centers were assessed in relation to the steps applicable to the type of services provided and by their respective governorate. The four governorates were compared accordingly and the results are displayed by UNICEF/WHO global criteria used for hospitals, but restricted to Steps (1), (2), (3), (5) and (6) only. Steps 4, 7, 8, 9 and 10 were not included, since none of the MCH services provided delivery services or inpatients services. A total of 77 MCH centers were surveyed: 24 in Alexandria, 22 in Sohag, 21 in Qaluibiya, and in Gharbia governorates.

Table (54) Comparison of the status of Baby Friendly (BFHI) global criteria for Step (1) for maternal and child health centers in Alexandria, Gharbia, Qaluibiya and Sohag governorates in Egypt: Criteria C1.1 C1.2 C1.3 C1.4 C1.5 No. % No. % No. % No. % No. % ALEXANDRIA 15 62.5 18 75 18 75 7 29.2 12 50 (24) GHARBIA (10) 1 10 1 10 1 10 9 90 1 10 QALUIBIYA 12 57.1 11 52.4 10 41.7 12 57.1 1 5.2 (21) SOHAG (22) 8 36.4 8 36.4 8 36.4 8 36.4 8 36.4 TOTAL (77) 34 44.2 38 49.4 36 48.1 36 46.8 22 28.6

Figure (50) 100 Comparison of the 80 status of Baby 60 Friendly (BFHI) global criteria for Step 40 C1.5 (1) for maternal and C1.4 20 C1.3 child health centers in 0 C1.2 Alexandria, Gharbia, Qaluibiya and Sohag ALEX. C1.1. GHRB. governorates. QALB. SG

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Table (55) Comparison of the status of Baby Friendly (BFHI) global criteria for Step (1) for maternal and child health units exposed to training versus those not recently exposed to any training in Baby Friendly:

Criteria C1.1 C1.2 C1.3 C1.4 C1.5 No. % No. % No. % No. % No. % Trained* 8 36.4 8 36.4 7 31.8 16 72.7 7 31.8 (22) No Training 26 47.3 26 47.3 25 45.5 15 27.3 16 29.1 )55)

80 60 40 Trained 20 Not 0 Trained C1.1 C1.2 C1.3 C1.4 C1.5

Figure (51) Diagrammatic representation of scores achieved for Baby Friendly (BFHI) global criteria for Step (1) by maternal and child health units exposed to training versus those not recently exposed to any training in Baby Friendly.

Teaching mother nursing fashion wear that facilitate skin to skin care and breastfeeding

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Training of MCH staff not only requires training in the 20 hour course of Baby friendly but also the WHO/UNICEF Infant and Young Child Feeding course for primary health care workers. Otherwise the criteria for assessing this step are the same as for hospitals.

Table (56) Comparison of the status of Baby Friendly (BFHI) global criteria for Step (2) for maternal and child health centers in Alexandria, Gharbia, Qaluibiya and Sohag governorates:

Criteria C2.1 C2.2 C2.3 C2.4 C2.5 C2.6

No. % No. % No. % No. % No. % No. %

ALEXANDRIA 4 16.7 4 16.7 0 0 0 0 0 0 0 0 (24) GHARBIA 7 70 7 70 6 60 3 30 6 60 3 30 (10) QALUIBIYA 1 4.8 1 4.8 1 4.8 1 4.8 1 4.8 1 4.8 (21) SOHAG 8 36.4 8 36.4 3 13.6 7 31.8 3 13.6 7 31.8 (22) TOTAL (77) 20 26 20 26 10 13 11 16.9 10 13 11 16.9

70 60 C2.1 50 C2.2 40 C2.3 30 C2.4 20 C2.5 C2.5 C2.6 10 C2.3 0 C2.1 ALEX GHB QAL SG

Figure (52) Diagrammatic representation of scores achieved for Baby Friendly (BFHI) global criteria for Step (3) by the maternal and child health centers at governorate level in Alexandria, Gharbia, Qaluibiya and Sohag.

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Table (57) Status of Baby Friendly (BFHI) global criteria for Step (2) by exposure to training:

Criteria C2.1 C2.2 C2.3 C2.4 C2.5 C2.6 No. % No. % No. % No. % No. % No. %

Trained 13 59.1 6 27.3 10 45.5 10 45.5 76/149 51 180/209 86.1 (22)

No 12 21.8 9 16.4 11 20 11 20 147/424 34.7 293/425 68.9 Training )55)

100

50 Trained

0 Not Trained C2.1 C2.2 C2.3 C2.4 C2.5 C2.6

Figure (53) Diagrammatic representation of Baby Friendly (BFHI) global criteria for Step (2) for maternal and child health units exposed to training versus those not exposed to training in the Ten steps.

A husband (companion) at birth attending antenatal classes to learn how to perform the natural ways for pain relief as per Mother friendly practices.

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Table (57) Comparison of the status of Baby Friendly (BFHI) global criteria for Step (3) for maternal and child health centers in Alexandria, Gharbia, Qaluibiya and Sohag governorates

C3.1 C3.2 C3.3 C3.4 C3.5

No. % No. % No. % No. % No. %

ALEXANDRIA 12 50 3 12.5 9 37.5 52/111 46.9 49/97 50.5 (24)

GHARBIA 10 100 3 30 3 30 22/22 100 19/22 86.4 (10) QALUIBIYA 7 33.3 6 28.6 14 66.6 101/170 59.4 99/170 58.2 (21)

SOHAG 17 77.3 0 0 0 0 55/100 55 39/55 70.9 (22) TOTAL (77) 46 59.7 12 15.6 26 33.8 130/403 32.3 206/344 59.9

100

80

60

40 C3.5 C3.4 20 C3.3 0 C3.2 ALEX C3.1 GHB QAL SG

Figure (54) Diagrammatic representation of scores achieved for Baby Friendly (BFHI) global criteria of Step (3) by maternal and child health centers in Alexandria, Gharbia, Qaluibiya and Sohag governorates.

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Table (58) Comparison of the status of Baby Friendly (BFHI) global criteria for Step (3) for maternal and child health units exposed to training versus those not recently exposed to any training in Baby Friendly:

C3.1 C3.2 C3.3 C3.4 C3.5 No. % No. % No. % No. % No. % Trained 16 72.7 6 27.3 6 27.3 60/97 61.9 48/94 51.1 (22) No 30 54.6 6 10.9 15 27.3 149/276 54 130/220 59.1 training (55) TOTAL 46 59.7 12 15.6 26 33.8 130/403 32.3 206/344 59.9 (77)

80

60

40

20

0 Not Trained C3.1 C3.2 Trained C3.3 C3.4 C3.5

Figure (55) Diagrammatic representation of scores achieved for Baby Friendly (BFHI) global criteria of Step (3) by maternal and child health centers by exposure to training.

Antenatal classes teach mother friendly practices for encouraging natural child birth which in turn facilitates successful breastfeeding through first hour skin to skin between mother and baby.

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Table (59) Comparison of antenatal education in Mother Friendly education in Alexandria, Gharbia, Qaluibiya and Sohag governorates:

Score for Alex (24) Gharbia Qaluibiya Sohag (22) Total Criteria (10) (21) of Mother Friendly (MF) No. % No. % No. % No. % No. % MF-2 34/127 26.8 39/59 66.1 32/59 54.2 105 42.9 /245 MF-3 35/127 27.6 47/59 79.7 29/59 49.2 111 45.3 /245 MF-5 2/91 2.2 0/14 0 19/100 19 21 10.2 /205 MF-6 5/91 5.5 0/14 0 45/100 45 20 9.8 /205

80 70 60 50 40 30 20 MF6 10 MF5 0 MF3 ALX MF2 GRB QAL SG

Figure (56) Comparison of the status of antenatal education in Mother Friendly practices according to the adapted BFHI global criteria by the maternal and child health center staff in the governorates of Alexandria, Gharbia and Sohag.

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Table (60) Comparison of the status of antenatal education in Mother Friendly practices according to the adapted BFHI global criteria in the hospitals providing maternity services in by exposure to training:

Score for Trained Not Trained Criteria of Mother Friendly 22 55 (MF) No. % No. % MF2 53/73 72.6 79/202 30.2 MF3 61/73 83.6 76/202 29.1 MF5 41/89 46.1 75/256 27.3 MF6 49/89 55.1 100/256 35.6

100

80

60

40

20 0 Not Trained MF2 Trained MF3 MF5 MF6

Figure (57) Comparison of the status of antenatal education in Mother Friendly practices according to the adapted BFHI global criteria in the hospitals providing maternity services in by exposure to training.

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Table (61) Comparison of the status of Baby Friendly (BFHI) global criteria for Step (5) for maternal and child health centers in Alexandria, Gharbia, Qaluibiya and Sohag governorates:

Alex (24) Gharbia (10) Qaluibiya Sohag (22) Total (77) (21)

No. % No. % No. % No. % No. %

C5-1 0 0 3 30 3 14.3 0 0 3 3.9 C5-2 0 0 0 0 0 0 0 0 0 0 C5-3 126/1 78.8 59/59 100 162/1 95.3 104/140 74.3 451/529 85.3 60 70

C5-4 105/1 65.6 59/59 100 111/1 65.3 112/140 80 387/529 73.2 60 70 C5-5 138/1 86.3 136/140 97.1 274/300 91.3 60

100 80 60 40 C5.5 C5.4 20 C5.3 0 C5.2 ALEX C5.1 GHB QAL SG

Figure (58) Diagrammatic representation of scores achieved for Baby Friendly (BFHI) global criteria of Step (5) by maternal and child health centers in Alexandria, Gharbia, Qaluibiya and Sohag governorates.

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Table (62) Comparison of the status of Baby Friendly (BFHI) global criteria for Step (5) for maternal and child health units exposed to training versus those not recently exposed to any training in Baby Friendly:

Score for Criteria of Step Trained (22) Not Trained (55) 5 No. % No. % 5-1 3 13.6 0 0 5-2 0 0 0 0 5-3 135/139 97.1 296/370 79.4

5-4 113/139 81.3 356/370 68.1 5-5 71/80 88.8 291/340 86.4

100

50

0 Not Trained C5.1 Trained C5.2 C5.3 C5.4 C5.5

Figure (59) Diagrammatic representation of scores achieved for Baby Friendly (BFHI) global criteria of Step (5) by maternal and child health centers in trained versus not trained.

يمكن تطبيق رعاية الجلد للجلد مع التوائم وارضاعهم معاً وال تحتاج األم التى لديها توائم أن تدخل لبن صناعى ألن لبنها يكفى الرضاعهم ولكنها تحتاج الى مساندة وتشجيع ودعم ممن حولها.

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Table (63) Comparison of the status of Baby Friendly (BFHI) global criteria for Step (6) for maternal and child health centers in Alexandria, Gharbia, and Sohag governorates:

Criteria of Alex (24) Gharbia (10) Sohag (22) Total Step 6

No. % No. % No. % No. %

C6-1 15 62.5 3 30 NA NA 18/34 52.9

C6-2 21 87.5 5 50 NA NA 26/34 76.5

C6-3 21 87.5 10 100 NA NA 31/34 91.21

C6-4 10 41.7 10 100 NA NA 20/34 58.8

C6-5 19/81 23.5 18/18 100 NA NA 37/99 37.4

C6-6 0/0 0 0/0 0 NA NA 0/0 0

C6-7 119/145 82.1 59/59 100 117/141 83 295/345 85.5

C6-8 33/46 71.7 18/19 94.7 133/172 77.3 184/237 77.6 These criteria were not assessed in Qaluibiya governorate.

100

50 C6.4 C6.3 0 C6.2 ALEX C6.1 GHB QAL SG

Figure (60) Diagrammatic representation of scores achieved for Baby Friendly (BFHI) global criteria: C6.1 to C6.4 of Step (6) by maternal and child health centers in Alexandria, Gharbia, and Sohag governorates.

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100 80 60 40 C6.8 20 C6.7 0 C6.6 ALEX C6.5 GHB QAL SG

Figure (61) Graphic representation of scores achieved for Baby Friendly (BFHI) global criteria C6.5 to C6.8 of Step (6) by maternal and child health centers in Alexandria, Gharbia, and Sohag governorates.

Table (64) Comparison of the status of Baby Friendly (BFHI) global criteria for Step (6) for maternal and child health centers by exposure to training: Criteria of Step 6 Trained (22) Not Trained (55) No. % No. % C6-1 12 54.5 21 38.2 C6-2 8 36.4 21 38.2 C6-3 19 86.4 27 49.1 C6-4 10 45.5 10 18.2 C6-5 65/78 83.3 27/91 29.7 C6-6 53/70 75.7 73/90 83.7 C6-7 137/149 92 332/360 92.2 C6-8 77/87 88.5 193/246 77.2

100

50

0 C6.1 C6.2 C6.3 C6.4 C6.5 C6.6 Trained Not Trained C6.7 C6.8

Figure (62) Comparison of status of Baby Friendly (BFHI) global criteria for Step (6) in maternal and child health centers by exposure to training.

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This study includes a representative sample of hospitals and MCH centers that were exposed to training in BFHI and another category of hospitals that were not exposed to the BFHI program inputs. The study showed no differences between the two groups of hospitals in steps 1, 5, 8, 10, Mother Friendly and the Code. However there were significant differences between both groups in steps 2, 4, 6, 7, 8 and 9. Although there is evidence that some important practices appeared to be adopted by many hospitals yet the manner in which they were adopted needed to be documented and examined closely in order to verify whether they are being done in line with the updated guidelines of practice in this field. These include the following: 1- The baby was given to the mother to see or hold immediately after birth in deliveries without general anesthesia (GA), but not to hold skin to skin (STS) for one hour. 2- The mother was shown correct positioning and attachment by medical staff, but not by the nursing staff. 3- The mother was able to demonstrate correctly how to express breastmilk, but resorted to use rubber bicycle horn pumps that are very dangerous as they can be a source of infection to mother and baby fed on expressed breastmilk. 4- Exclusively breastfeeding at birth was practiced in all maternity wards. Unfortunately this was not the case in neonatal units, where babies were exposed to formula feeding simply because mothers were not allowed to stay in the hospitals with her baby. This requires changing the hospital regulations to allow admission of the mother to stay with her baby. This was not allowed previously because of the strict infection control measures. However, emerging medical evidence shows that this reduces cross infection (hospital acquired infections) and calls for mothers to be admitted to the NCU; as exposing her to NCU microorganisms will help her produce antibodies against them, thus protecting her baby from cross infection. 5- Rooming-in was practiced also in maternity units, but again not in the neonatal care units. 6- Guiding mothers to on-demand feeding and feeding cues of her baby was inadequate. This practice is important as it helps stimulate more milk and allows more STS contact with feeding, but it was impeded by the tight and front closed clothing the mothers are wearing. The rationale of the expanded integrated Baby Friendly updated initiative is to reach all health care practices, educational systems and specialties, thereby becoming the norm of perinatal practices. We were hoping to see whether the implementation process over the past years reached indirectly to the health facilities that were not directly exposed to the program inputs. For instance the integration of correct attachment and positioning to the breast in the IMCI program did have a significant positive effect on the physicians’ practices but unfortunately not the nurses. The

Page 115 MCH/MoHP-MCFC-UNICEF BFHI Muti-Center Needs Assessment Survey, 2016 latter consistently continued to describe the older methods of assisting mother to breastfeed, linked to formula feeding, i.e. placing baby in semi-sitting rather straight and aligned and facing. This was directly attributed to IMCI concepts that were successfully integrated in the medical education of doctors but not for the nurses. This could also be due to the latter program being successfully implemented in medical and nursing faculty schools but not the nursing schools. It was expected that the neonatal care program would influence the dissemination of the second part of step 5: milk expression and how to maintain milk supply. However this was not evident from the survey. Also it was expected that maternity care programs would address early first hour STS as a strategy for reducing maternal mortality. Unfortunately this was very poorly implemented in all the hospitals that were surveyed. Also it was expected that the infection control program, with all its successes, would be able to stress on the rooming-in and reverse rooming-in and on-demand feeding in the first few days of life and minimizing use of bottle and pacifiers as a strategies for reduction of cross infection (nosocomial or hospital acquired infection). A positive finding that seemed to make its way through different programs, but probably mostly through the Family Planning program, was the exclusive breastfeeding from birth up to six months, although still low, yet many physicians and nurses mentioned it as routine practice and were quite aware of its importance. Although most programs in primary health care were stressing it, there were some conflicting messages emerging from the distribution of low priced infant milk formula to the “needy” mothers attending MCH. Each and every mother considers herself a “needy” mother and has poor confidence in her milk and her ability to breastfeed as she cannot see her milk but can see the milk in the bottle and is satisfied to see her baby finish it all. Stool and urine output and sometimes excessive regurge of milk, may make mothers think her baby does take her milk. Hence it is important to regularly weigh the baby to show her that her baby is gaining weight on her milk. Unfortunately the actual gain in weight (beyond the birth weight) does not happen except after 2-3 weeks, by then the mother has panicked, lost confidence and has gone to formula feeding. To this day- doctors still think that if the baby does not gain weight by the third week of life then milk is “scanty” (a favorite term created by industry) and they need to add a formula. Hence building mother’s confidence by counseling and using the WHO growth charts of breastfed to show them how their baby suddenly steeps up in weight at 5 and 6 weeks of age is an essential practice that needs to be part of the system. Close follow up in the first six weeks of life by home visitations is very important, but is quite lacking as shown by the low criteria of Sep (10) demonstrated by most of the hospitals visited. Hence integration of the Ten Steps through all the programs is very important and can have a reinforcing effect on Baby Friendly. The concept of “verticalization” of programs is still a problem. This does not implicate that BFHI should only be integrated into other programs. The national Baby friendly program is a fully structured stand-alone program but can also have powerful inputs when integrated with other programs too. Hospital based infection control can benefit from step 4

Page 116 MCH/MoHP-MCFC-UNICEF BFHI Muti-Center Needs Assessment Survey, 2016 and 7, while IMCI can benefit from step 5 and 8, EPI can benefit from step 6 and step 8, while safe motherhood can benefit from step 3, Family planning can benefit from step 6 and step 9, while non-communicable disease control can benefit from all the steps and their long term effect on mother and baby health outcomes. Hence integration is a means for reinforcing and strengthening programs by boosting the practices to become eventually embedded into the health system as the norm in medical practice. Another aspect when addressing interventions for achieving global health and optimal nutritional status is to have a more holistic overview of our health and nutrition problems by looking at other developmental aspects as education, sanitation, living conditions and other social problems. The major part of our developmental problems is education and high rates of illiteracy. The number and rate of female illiteracy is generally more extensive in rural areas than urban areas. The illiteracy rate in rural areas reached a percentage of 62% compared to 27% of the urban areas. Furthermore, the female illiteracy rate is greater than the male illiteracy rate reaching 69% for females and 31% for males (EAEA, 2008). The distribution of illiteracy rates shows that 40% are in the under 45 years of age group compared to 55% in the age over 45 years. Moreover one in four (25%) of the illiterate women are in the childbearing age and this is more so in the rural areas, especially in rural where 3 in 4 women suffer illiteracy. Such findings indicate that any health problem needs to take into account the developmental factors (EDHS, 2014). Hence illiteracy stands as one of the major barriers to promotion and protection of breastfeeding; as such populations become an easy target to traditional misconceptions and industry misinformation that result in poor breastfeeding practices and formula feeding, increasing the burden of morbidity and early mortality. Poverty is often used as an excuse for all our developmental problems. The fact is that empowering these populations to seek to improve their ways of thinking by educating themselves, seeking innovative and sustainable ways of increasing their income, inspiring them with confidence and power to be the change they want to see in the world, are essential life skills to for such populations to achieving global development. Ideally we suggest that any strategy for breastfeeding promotion or other health program should integrate education, social wellbeing, behavioral change and economic aspects as a means for achieving sustainability and thereby meeting the millennium development goals of health and optimal nutrition for every child and mother.

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29. Kramer M. S, Chalmers B, Hodnett E. D, Sevkovskaya Z, Dzikovich I, Shapiro S, et al. (2001). Promotion of Breastfeeding Intervention Trial (PROBIT): A randomized trial in the Republic of Belarus. The Journal of the American Medical Association. 285(4): 413– 420. 30. Kramer MS and Kakuma R. (2002) Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev; Issue 1; CD003517 10.1002/14651858. CD003517. PMID: 11869667. 31. Kramer MS, Guo T, Platt RW, Sevkovskaya Z, Dzikovich I, Collet JP, Shapiro S, Chalmers B, Hodnett E and Vanilovich I. (2003) Infant growth and health outcomes associated with 3 months compared with 6 months of exclusive breastfeeding. Am J Clin Nutr. 78: 291–295. 32. Kramer MS, Kakuma R. (2004) The optimal duration of exclusive breastfeeding: a systematic review. Adv Exp Med Biol. 554: 63-77. 33. Kwan M.L, Buffler P.A, Abrams B, Kiley V.A. (2004) Breastfeeding and the risk of childhood leukemia. A Meta-analysis. Public health reports. 6: 521-535. 34. Lauer J.A, Betrán A.P, Barros A.J, de Onís M. (2006) Deaths and years of life lost due to suboptimal breast- feeding among children in the developing world: a global ecological risk assessment. Public Health Nutr. 6: 673–85. 35. McGuire W, Anthony M.Y. (2003) Donor human milk versus formula for preventing necrotising enterocolitis in preterm infants: systematic review. Arch. Dis. Child. Fetal Neonatal Ed; (1): 11–4. 36. Mortensen E, Michaelsen K, Sanders S, Reinisch J. (2002): The association between duration of breastfeeding and adult intelligence. JAMA. 18: 2365–71. 37. Naylor AJ. (2001) Baby-Friendly Hospital Initiative Protecting, promoting, and supporting breastfeeding in the twenty-first century. Pediatr Clin North Am. 48(2):475-483. 38. Nissan E. (1996) Different patterns of oxytocin, prolactin but not cortisol release during breastfeeding in women delivered by caesarean section or by the vaginal route. Early Hum Dev. 45(1-2):103-18. 39. Oddy WH, Holt PG, Sly PD, et al. (1999) Association between breast feeding and asthma in 6 year old children: findings of a prospective birth cohort study. BMJ. 319 (7213): 815–9. 40. Olsson C, Lyon P, Hörnell A, Ivarsson A, Sydner Y.M (2002) Breast-feeding protects against celiac disease. American Journal of Clinical Nutrition. (5): 914–921. 41. Owen CG, Martin RM, Whincup PH, Davey Smith G and Cook. DG (2005) Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published evidence. Pediatrics. 115:1367-77. 42. Raghuveer TS, Belmont JM.(2008) Human milk intake and retinopathy of prematurity in extremely low birth weight infants. Pediatrics. 122(3):686-687. 43. Guo AY, Stevens BW, Wilson RG, et al. (2014) Early life environment and natural history of inflammatory bowel diseases. BMC Gastroenterology. 14:216. doi:10.1186/s12876-014-0216-8. 44. Rodríguez AMP. (2011) Medicalization of Labor: A Type of Violence against Women. CGBI Breastfeeding Exclusive 3 Issue 4.15.2011. 45. Sharif H, Abul-Fadl AMA, Shawki M., ElTahawy E, Elwan N (2011) Effectiveness of a computerized tool for the Baby Friendly Hospital Initiative in Egyptian settings. MCFC Egyptian Journal of Breastfeeding. 2l:102- 114. 46. Shawki M., Abul-Fadl AMA, Elwan N, Noawara M, Foda A.and Sharif H. (2011) An assessment of mother friendly in maternity services in Egypt. MCFC Egyptian Journal of Breastfeeding. 2: 79-87. 47. Sørensen HJ, Mortensen EL, Reinisch JM, Mednick SA (2005) Breastfeeding and risk of schizophrenia in the Copenhagen Perinatal Cohort. Acta Psychiatrica Scandinavia 112:26-29. 48. UNICEF – WHO (2006) Expanded Integrated Baby Friendly Hospital Initiative for promoting breastfeeding in Baby friendly Hospitals, Section 2 UNICEF, New York. 49. UNICEF /WHO (2009) Expanded Integrated Baby Friendly Hospital Initiative Update for promoting breastfeeding in Baby friendly Hospitals, UNICEF, New York. 50. UNICEF 1990-2005: Celebrating the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding: Past Achievements, Present Challenges and Priority Action for Infant and Young Child Feeding. 2nd edition. UNICEF Innocenti Research Centre, Florence, Italy; 2006. 51. Waldenstrom U, Hildingsson I, Rubertsson C, and Radestad I. (2004). A negative birth experience: Prevalence and risk factors in a national sample. Birth. 31(1):17–27. 52. World Health Organization (2002) The optimal duration of exclusive breastfeeding. Report of an Expert Consultation. WHO, Geneva, Switzerland. 53. World Health Organization. (2001) Global strategy for infant and young child feeding, the optimal Duration of Exclusive Breastfeeding. WHO Geneva, Switzerland. 54. Young T , Martens P, Taback S, Sellers E, Dean H, Cheang M and Flett B. (2002) Type 2 diabetes mellitus in children - Prenatal and early infancy risk factors among native Canadians. Archives of Pediatrics and Adolescent Medicine. (7): 651–655.

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RESEARCH PARTICIPANTS

Ministry of Health and Population (MoHP) Facilitators Dr. Emad Ezzat, Head of Health Care and Nursing Sector Dr. Soad Abdel Mageed, Undersecretary of Central Department of Integrated Health Dr. Nahla Roushdi, Director General MCH/MoHP Dr. Adel Shakshak, Head Nutrition unit, Dr. Israa Aly Ahmed, assistant lecturer, MCH Family Medicine Department Dr. Dina Abdel Hady, BFHI Coordinator Dr. Farida Samy Abdo, Family Medicine Department Mother Child Friendly Care Association (MCFC) supervisors & investigators: Benha Faculty of Medicine, Benha Dr. Azza Abul-Fadl, Professor of Pediatrics, University: President MCFC Prof. Dr. Hala ElHady, Community Medicine Dr. Samaah Zohair, Specialist Nutritionist, Dr. Ola Gala Ali Behairy, Senior Lecturer, IBCLC, Secretary General MCFC Pediatric Department Dr. Mona Taha, Specialist Pediatrician, Qaluibiya Health Directorate: IBCLC, Board member Dr. Mohamed Abu-ElKasem Mohamed, PHC Dr. Amany Younis, Specialist Pediatrician, Dr. Mona ElSherbini, Family Physician IBCLC IBCLCs Dr. AlShaimaa Hassan, IBCLC, Alexandria UNICEF, Egypt, Cairo Office: Dr. Dalia Abdel Hamid, IBCLC Dr. Magdy ElSanady, Chief Health & Nutrition Dr. Alia Hafiz, Nutrition Specialist Governorate Facilitators Dr. Esmat Mansour, Consultant Sohag Health Directorate: Dr. Yousri M.M. Bayoumi, Undersecretary Primary Investigators MoHP Sohag Egyptian Medical Women Association Dr. Mohamed Abdel Al, former (EMWA): Undersecretary MoHP Sohag Dr. Omima Abu Shady, President EMWA, Dr. Hani Lotfi, MCH/MoHP, Sohag MoHP Professor of Parasitology, Cairo University Alexandria Health Directorate: Dr. Thoraya Abdel Hamid, Professor of Dr, Magdy Hegazi, Undersecretary Community Medicine, AlZahraa University Alexandria Health Directorate Dr. Amina Gheith, EMWA Dr. Mohga Fikry, MoHP/ MCH, Alexandria Faculty of Medicine, Sohag University: Health Directorate Dr. Eman AbdelBaset Mohamed, Professor Qaluibiya Health Directorate: and Head of Community Medicine Dr. Mohamed Lashin, Undersecretary MoHP Department Qaluibiya Dr. Ayat Khalaf Ahmed, assistant lecturer, Dr. Maissa Rashed, MCH/MoHP Qaluibiya Family Medicine Department

Page 120 تحديد احتياجات المستشفيات الصديقة للطفل اإلدارة المركزية لرعاية األمومة والطفولة بوزارة الصحة منظمة األمم المتحدة لألطفال )اليونيسف( جمعية أصدقاء رعاية األم والطفل

مسح متعدد المراكز لتحديد احتياجات المستشفيات الصديقة للطفل دعم وحماية ومساندة الرضاعة الطبيعية من خالل المبادرة المحدثة والموسعة والتكاملية للمستشفيات الصديقة للطفل لمنظمة األمم المتحدة لألطفال )اليونيسف( ومنظمة الصحة العالمية

اإلدارة المركزية لرعاية األمومة والطفولة بوزارة الصحة والسكان جمعية أصدقاء رعاية األم والطفل بدعم مكتب منظمة األمم المتحدة لألطفال )اليونيسف( بالقاهرة بالشراكة مع مديرية الشئون الصحة باألسكندرية كلية الطب بجامعة بنها ومديرية الشئون الصحية بالقليوبية كلية الطب بجامعة سوهاج ومديرية الشئون الصحية بسوهاج الجمعية المصرية الطبية النسائية بجامعة القاهرة

جمهورية مصر العربية 2016

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تحديد احتياجات المستشفيات الصديقة للطفل اإلدارة المركزية لرعاية األمومة والطفولة بوزارة الصحة منظمة األمم المتحدة لألطفال )اليونيسف( جمعية أصدقاء رعاية األم والطفل

المقـدمـة

يتعرض قرابة ثلث أطفال العالم إلى التقزم نتيجة الممارسات الخاطئة فى التغذية المبكرة وباألخص في الرضاعة الطبيعية. فسوء التغذية يعد من األسباب الرئيسية التي تؤدي للوفاة سواء بشكل مباشر أو غير مباشر، حيث يعد مسئول ا عن ثلث وفيات األطفال دون سن الخامسة تقريب ا، وتحدث أكثر من ثلثي تلك الوفيات نتيجة لممارسات التغذية غير السليمة للطفل خالل عامه األ ّول وباألخص الحرمان من الرضاعة المطلقة خالل األشهر الستة األولى من العمر. توصي منظمة الصحة العالمية بالشروع في إرضاع األطفال طبيعي ا خالل الساعة األولى من الولدة، والقتصار على الرضاعة طوال األشهر الستة األولى من عمرهم مع إدخال قسط كاف من األغذية التكميلية المأمونة والمناسبة بعد 6 أشهر من العمر مع الستمرار في الرضاعة الطبيعية حتى بلوغهم العامين أو أكثر من ذلك. تمثّل الرضاعة الطبيعية وسيلة منقطعة النظير لتوفير الغذاء األمثل الذي يكفل للر ّضع النمو والنماء بطريقة صحية؛ وهي أيض ا ركن أساسي فى عملية اإلنجاب ولها آثار داعمة على صحة األمهات. وقد أظهرت عملية استعراض البيّانات أ ّن القتصار على الرضاعة المطلقة طوال األشهر الستة األولى من حياة الطفل يش ّكل أنسب الطرق لتغذية الرضيع وحمايته من اإلصابة باألمراض المعدية في حينه وباألمراض المزمنة فيما بعد، إلى جانب الحماية من سوء التغذية والبدانة وسرطان الدم وأمراض القلب والدورة الدموية واألمراض المناعية. ويتحتم بعد إتمام الستة أشهر إدخال األغذية التكميلية للرضيع مع الستمرار في إرضاعه طبيعي ا حتى بلوغه العامين من العمر أو أكثر لضمان أفضل نمو وتطور وذكاء ذهنى وعاطفى والحماية من الضطرابات السلوكية واألمراض النفسية. ولتمكين األمهات من البدء بالرضاعة الطبيعية والعتماد عليها حصريا طيلة ستة أشهر توصي كل من منظمة الصحة العالمية واليونيسيف بما يلي :  الشروع في إرضاع الطفل طبيعياً في غضون الساعة األولى من ميالده من خالل مالمسة الجلد للجلد.  االقتصار على الرضاعة الطبيعية- وذلك يعني أ ّن الطفل ال يتلقى إالّ لبن األ ّم دون إضافة أ ّي أغذية أو مشروبات ، بما في ذلك الماء.  إرضاع الطفل بناء على طلبه ـ أي كلّما ظهرت عليه العالمات الدالة على الرغبة فى الرضاعةـ طوال النهار وباألخص أثناء الليل.  عدم إعطاء زجاجات اإلرضاع أو الم ّصاصات أو اللهايات. إن لبن األم هو أ ّول غذاء طبيعي يتناوله الرضيع، وهو يوفّرله كل ما يلزم من الطاقة والعناصر المغذية في األشهر األولى من حياته، كما يغطي نحو نصف احتياجات الطفل التغذوية أو أكثر خالل الشطر الثاني من العام األ ّول، ونحو ثلث تلك االحتياجات خالل العام الثاني من حياته. ويسهم لبن األم في النماء الح ّسي والمعرفي وفي حماية الرضيع من األمراض المعدية والمزمنة. ويسهم االقتصار على الرضاعة الطبيعية في الحد من وفيات الر ّضع الناجمة عن أمراض الطفولة الشائعة، مثل اإلسهال وااللتها الرئوي، ويساعد على التعافي من األمراض بسرعة. ويمكن قياس تلك اآلثار في كل من المجتمعات الشحيحة الموارد والمجتمعات الميسورة.

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تحديد احتياجات المستشفيات الصديقة للطفل اإلدارة المركزية لرعاية األمومة والطفولة بوزارة الصحة منظمة األمم المتحدة لألطفال )اليونيسف( جمعية أصدقاء رعاية األم والطفل

وعلى الرغم من أ ّن الرضاعة تعد من الممارسات الطبيعية إال إنّها تمث ّل أيضاً سلوكاً يُكتسب بالتعلّم، وقد أطلقت منظمة الصحة العالمية واليونيسيف مبادرة "المستشفيات الصديقة للر ّضع"، التي تشتمل على عشر خطوات لضمان نجاح الرضاعة الطبيعية تكمن ـ حسب البيان الصادر عن المنظمتين ـ في حماية الرضاعة وتشجيعها ودعمها. وقد تم تلخيص البيّنات على فعالية الخطوات العشر في دليل متخذى القرار لمبادرة المستشفيات الصديقة للطفل. تم تنفيذ المبادرة بداخل قرابة 16000 مستشفى في 171 بلداً وقد أسهمت المبادرة في تحسين نسبة األخذ بمبادئ االقتصار على الرضاعة الطبيعية في جميع أنحاء العالم. وفي حين تساعد خدمات الممارسات الصديقة لألم على زيادة معدالت الشروع في الرضاعة الطبيعية واالقتصار عليها، فإ ّن الدعم على جميع مستويات النظام الصحي يعد من األمور الضرورية لمساعدة األمهات على االستمرار في الرضاعة. وفىىى مصىىر أظهىىرت بيانىىات المسىى الىىديموجرافي األخيىىر 2014( انخفاضىىا فىىى معىىدالت الرضىىاعة الطبيعية المطلقة من الوالدة الى 4-5 أشهر وصل الى 13% و أن أكثر من نصىف المواليىد ال يبىدأون الرضىىاعة مىىن الثىىدي خىىالل السىىاعة األولىىى وأن 30% مىىن األطفىىال دون 6 شىىهور قىىد تعرضىىوا الىىى زجاجة إرضاع. وعلى الرغم من أن هناك 126 مستشفى قىد تىم تقييمهىا ومنحهىا لقىب مستشىفى صىديقة للطفىل فىى عىام 1996 إال أن هذا العدد تضاءل الى حد كبيىر لعىدم المتابعىة والتقيىيم المسىتمر لهىذا البرنىام سىواء فىى المستشفيات أو المراكز الصحية وفى 2008 قمنا بعمل مس ميدانى فىى 12 محافظىة لدراسىة الوضىع فى تشجيع الرضاعة تبعاً للخطوات العشر فأظهرت الدراسة الحاجىة الىى إعىادة تفعيىل البرنىام وبعىد أحداث 2011حيث توقفت الكثير من التدخالت وتباطأت أنشطة الوزارة فى هذا المجال ولم تتمكن من مباشرة هذا البرنام كما ينبغى ولىذلك قمنىا بعمىل دراسىة الحقىة فىى 2015 اسىتهدفت تقيىيم احتياجىات المستشفيات التى خضىعت للتىدريب ومقارنتهىا بالمستشىفيات المماثلىة فىى بىاقى المحافظىة لقيىاس نتىائ التدخل ووضع خطط لتوسيع نطاق التطبيق فى أنحاء البالد.

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تحديد احتياجات المستشفيات الصديقة للطفل اإلدارة المركزية لرعاية األمومة والطفولة بوزارة الصحة منظمة األمم المتحدة لألطفال )اليونيسف( جمعية أصدقاء رعاية األم والطفل

ملخص نتائ الدراسة

لقد طبق المس الميداني الكتشاف احتياجات المستشفيات الصديقة للطفل فى 31 مستشفى والدة بها وحدة رعاية لحديثى الوالدة( و 77 وحدة رعاية فى محافظات األسكندرية والغربية و القليوبية وسوهاج باستخدام أداة التقييم التي وضعتها منظمة األمم المتحدة لألطفال اليونيسف( ومنظمة الصحة العالمية للمستشفيات الصديقة للطفل. و احتوى المس على عينة ممثلة من األمهات الوالدات سواءاً بالمستشفى والمترددات على الوحدات الصحية للفحص المعملى للكشف عن نقص الغدة الدرقية فى األسبوع األول بعد الوالدة أو التطعيمات خالل شهرين من الوالدة و قد وصل عدد اللقاءات التى تمت مع األمهات المرضعات الى 777 كما تمت لقاءات مع 443 من السيدات الحوامل. واستهدف البحث الميدانى العاملين الصحيين من األطباء والتمريض وقد تمت لقاءات مع 781 طبيب وممرضة من المستشفيات و554 من مراكز ووحدات الرعاية، كما تمت لقاءات مع الفئات المساعدة كالعامالت والمثقفات والرائدات واألخصائيات االجتماعيات وكان العدد 260 مستشفى و368 وحدة رعاية . وقد قمنا بتحليل النتائ باستخدام أداة التحليل التى وضعتها منظمة اليونيسف ومنظمة الصحة العالمية للمستشفيات الصديقة للطفل وهى االستمارات التلخيصية للبيانات المجمعة للفئات المختلفة لتقييم كل خطوة من الخطوات العشر على حدى طبقاً للمعايير والمواصفات العالمية المتفق عليها. وقد أظهرت الدراسة التى تمت فى مستشفيات الولدة النتائج اآلتية : الخطوة األولى : "وجود سياسة مكتوبة يتم توصيلها بشكل روتيني الى جميع العاملين" 1- هناك سياسة مكتوبة ومعروضة للجميع العاملين والمترددين( لدعم وحماية الرضاعة الطبيعية فى 11 مستشفى (%34.37) فقط. 2- السياسة تحوى الخطوات العشر والمدونة الدولية لحماية األمهات المرضعات من التسويق للمنتجات التى تسوق كبدائل للبن األم( فى 8 مستشفيات %25.0(. 3- السياسة معروضة فى جميع األماكن التى تتردد عليها األمهات وبلغة سهلة مع توضيحات بسيطة يمكن أن تفهمها جميع األمهات وذلك فى 10 مستشفيات %31.25(. 4- وجود آلية لرصد وتقييم السياسة فى 6 مستشفيات %18.75(. الخطوة الثانية : "تدريب جميع العاملين بالخدمات الصحية الموجهه لألم والطفل" : 1- وجود منه تدريبى فى تشجيع الرضاعة فى 6 مستشفيات %18.18( . 2- عرضت كل الخطوات العشر والمدونة بشكل واف في التدريب فقط فى 5 مستشفيات . (15.15% 3- أشارت سجالت التدريب إلى أن 80٪ من الكادر الطبي المستهدف قد تلقوا تدريبا لمدة 20ساعة على األقل بماال يقل عن 3 ساعات من الخبرة السريرية الخاضعة لإلشراف في 5 مستشفيات %15.15(.

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تحديد احتياجات المستشفيات الصديقة للطفل اإلدارة المركزية لرعاية األمومة والطفولة بوزارة الصحة منظمة األمم المتحدة لألطفال )اليونيسف( جمعية أصدقاء رعاية األم والطفل

4- وأكد 29٪ من الكادر الطبي أنهم تلقوا هذا التدريب، بينما أجا 45.7٪ على المعلومات األساسية لدعم الرضاعة الطبيعية 5- تلقى ثلث الموظفين المساعدين في هذه المستشفيات تهيئة على السياسة . الخطوة الثالثة : "إعالم جميع الحوامل بأهمية الرضاعة الطبيعية وكيفية ممارستها بما فى ذلك تحضيرهن للبدء بالرضاعة بمالمسة الجلد للجلد وفوائد ذلك ألطفالهن": هذه الخطوة قد تم تقييمها فى مراكز الرعاية وليس بالمستشفيات. الخطوة الرابعة: "بدء الرضاعة فى غضون نصف ساعة من الولدة بوضع المولود فور الولدة مالمس ا الجلد للجلد على األم لمدة ساعة يبدأ من خاللها الرضاعة على ثدى األم" : 1- فى الوالدات الطبيعية أو القيصرية بالتخدير الشوكي أو فوق الجافية أعطيت 53.5% من األمهات أطفالهن في غضون 5 دقائق من الوالدة. وقد ارتفعت هذه المعدالت فى المستشفيات التى خضعت للتدريب الى %73.3. 2- في الوالدات القيصرية بالتخدير الكلي أعطي الطفل لألم بعد 5 دقائق من اإلفاقة في ٪21.7. ومن اإليجابيات الجديرة بالذكر أن إجراء القيصرية بالتخدير الكلي قد انخفض بشكل كبير وحل محله التخدير الشوكي. وقد ارتفعت هذه المعدالت فى المستشفيات التى خضعت للتدريب الى %50. 3- وكان اجراء وضع المولود على أمه فور الوالدة لممارسة الجلد للجلد لمدة ساعة واحدة ـ فقط في 18.4% من حاالت الوالدة الطبيعية أو القيصرية مع التخدير الشوكي أو فوق الجافية وفي 4.3٪ من األمهات الالتى تعرضن للوالدة القيصرية مع التخدير الكلي، ولم تتأثر هذه المعدالت بالتعرض للتدريب. 1- في 30.0٪ من المرافق قام المنوط بمالحظة األم -أثناء ممارستها الجلد للجلد مع وليدها بتوجيهها للتعرف على عالمات الرغبة فى الرضاعة واستعداد طفلها للرضاعة الطبيعية 2- شجعت وحدة رعاية األطفال حديثي الوالدة أمهات األطفال الرضع على ممارسة وضع الطفل الجلد للجلد في ٪30.8. الخطوة الخامسة : "تعليم األم كيفية اإلرضاع وكيفية اإلبقاء على لبنها إذا فصل عنها الطفل" 1. أكد موظفو اإلشراف أن إداراتهم تمن األمهات الالتى تتعرضن لخطر التوقف عن الرضاعة اهتماما خاصا بالمساعدة والتوجيه الكافي لكيفية اإلرضاع في 51.5٪ من الحاالت، وقد ارتفعت هذه المعدالت فى المستشفيات التى خضعت للتدريب الى ٪71.4. 2. في حاالت نادرة لم تتمكن األمهات من اإلرضاع فى 38.7 ٪ . وقد أوضحت هؤالء األمهات كيفية إعداد وإطعام بدائل لبن األم من خالل تطبيق ما تعلمن . 3. ذكر 72.7٪ من الكادر الطبي أنهم يعلمون األمهات طريقة اإلرضاع الوضع والتعلق الصحي ( كما قاموا بوصف الطريقة الصحيحة لذلك، وأفاد 64.7٪ أنهم يعلمون األمهات طريقة تعصير اللبن وتمكنوا من وصف طريقة تعصير الثدي جيدا ً، أوإنهم في حال لم يتمكنوا من شرح ذلك لألم يتم إحالتها إلى من يمكنه مساعدتها فى ذلك. وقد ارتفعت نسبة

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تحديد احتياجات المستشفيات الصديقة للطفل اإلدارة المركزية لرعاية األمومة والطفولة بوزارة الصحة منظمة األمم المتحدة لألطفال )اليونيسف( جمعية أصدقاء رعاية األم والطفل

المعيار الخاص بتعليم األم الوضعية فى المستشفيات التى خضعت للتدريب الى ٪82 ولكن لم يتأثر المعيار الخاص بتعليم األم كيفية استخراج اللبن من الثدي. 4. وأكدت٪ 41.4 من األمهات أن العاملين قدموا المزيد من المساعدة للرضاعة الطبيعية في الرضعة الثانية للطفل أو في غضون 6 ساعات من الوالدة ولكن 67.5٪ كن قادرات على عرض الطريقة الصحيحة للوضع والتعلق السليم أثناء الرضاعة و ذكرت 25٪ أن العاملين قد قاموا بتعليمهن كيفية تعصير اللبن أو قدموا لهن مطوية مكتوبة عن كيفية القيام بذلك، وقد ارتفعت هذه المعدالت فى المستشفيات التى خضعت للتدريب الى 59.5 ٪ و 69.6٪ و34.9 ٪ على التوالى . 5. أفادت 24.9٪من أمهات األطفال في الرعاية المركزة أنه قد تم توجيههن الى البدء فى تعصير الثدي في غضون 6 ساعات من والدة أطفالهن، وأفادت 30.7٪ أنه قد عرض عليهن طريقة تعصير اللبن وحفظه بطريقة آمنة، وتمكنت 28.3٪ منهن من عرض الطريقة الصحيحة لتعصير اللبن، بينما ذكرت 32.8٪ أن الطاقم الطبى وجهها الى أنها بحاجة إلى ارضاع طفلها أو شفط اللبن 6 مرات أو أكثر خالل ال 24 ساعة للحفاظ على إدرار اللبن. وقد ارتفعت هذه المعدالت فى المستشفيات التى خضعت للتدريب الى 40.7 ٪ و51.7٪ و58.3٪ على التوالى لموصفات معايير الخطوة الخامسة رقم 5.10 و5.12 و5.13 ولكن ليس لرقم 5.11. الخطوة السادسة : "عدم إعطاء المولود أية سوائل أو أغذية إل فى الحالت الطبية المحدودة" 1- لم توجد سجالت طبية متوفرة لرصد بيانات تغذية األطفال حديثي الوالدة. وتشير بيانات غير رسمية إلى أن 75٪ على األقل من المواليد كاملى النمو في العام الماضي قد رضعوا طبيعياً فى 39.3٪ من المستشفيات، وأن هناك بروتوكوالت أو معايير للرضاعة الطبيعية وإدارة تغذية الرضع تتماشى مع معايير برنام المستشفيات الصديقة لألطفال والمبادئ التوجيهية القائمة على األدلة في 18.2٪ من المستشفيات فقط، وقد ارتفعت هذه المعدالت إلى 71.4 ٪ و 57.2٪ في المستشفيات التى خضعت للتدريب على التوالى. 2- أكد 72.7٪ من المسؤلين بالمستشفيات المعنية أن المواد التي توصي بالتغذية ببدائل لبن األم ال يتم توزيعها على األمهات. وقد ارتفع هذا المعدل فى المستشفيات التى خضعت للتدريب الى 100 ٪ . ويتم إعداد األغذية البديلة بعيدا عن األمهات المرضعات في 63.6٪ ، وقد ارتفع هذا المعيار فى المستشفيات التى خضعت لتدخل التدريب الى 71.2 ٪. 3- وأكد 58.8٪ من العاملين أنه إذا تم وصف أغذية بديلة فإن ذلك يكون استنادا ً إلى أسبا طبية مقبولة أو خيارات واعية لتلقي غذاء خالف لبن األم، وأنه فى 39.2٪ من المستشفيات يتم نص األمهات بالمشورة حول مخاطر هذه البدائل. وقد ارتفعت هذه المعدالت فى المستشفيات التى خضعت لتدخل التدريب الى 90.9 ٪ و 100٪ على التوالى. 4- أفادت 68.5٪ من األمهات المرضعات أن أطفالهن قد تلقوا لبن األم فقط، أو إذا أعطوا أي شيء آخر فإن ذلك كان مبررا. وقد ارتفع هذا المعيار فى المستشفيات التى خضعت لتدخل التدريب الى ٪90.5 .

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تحديد احتياجات المستشفيات الصديقة للطفل اإلدارة المركزية لرعاية األمومة والطفولة بوزارة الصحة منظمة األمم المتحدة لألطفال )اليونيسف( جمعية أصدقاء رعاية األم والطفل

5- في وحدة رعاية األطفال حديثي الوالدة أبلغت أمهات األطفال أنه قد تم شرح أهمية لبن األم المعتصر وأخطار البدائل األخرى لهن من قبل العاملين فى 38.9٪ من المقابالت. وقد ارتفع هذا المعيار فى المستشفيات التى خضعت لتدخل التدريب الى ٪75 . 6- ذكر موظفو الصحة أنهم ال يصفون أو يعطون البدائل إال ألسبا طبية مقبولة .في 85.8٪. وقد ارتفع هذا المعيار فى المستشفيات التى خضعت للتدريب الى ٪91.3 . 7- ذكر 63.9٪. من الكادر غير الطبي أنه ينص األمهات بأهمية الرضاعة الطبيعية الحصرية .وقد ارتفع هذا المعيار فى المستشفيات التى خضعت للتدريب الى ٪79.7 . الخطوة السابعة : "مالزمة الوليد لألم على مدار 24 ساعة )نهار ا وليالا(" 1- أظهرت المالحظات في عنابر الوالدة والغرف ومناطق المراقبة أن 62.03٪ من األطفال واألمهات يسكنون معاً، أو ان الفصل كان ألسبا مقبولة. وذكرت 88.9٪ من األمهات بأن أطفالهن بقوا معهم منذ الوالدة، أو إذا لم يكن الحال كذلك، كانت هناك أسبا مبررة. وقد ارتفعت هذه المعدالت فى المستشفيات التى خضعت للتدريب الى 79.8 ٪ و ٪92.5 على التوالى. 2- يتم تشجيع األمهات في مراكز الرعاية المركزة على قضاء أكبر وقت ممكن مع أطفالهن ورعايتهم الجلد للجلد بممارسة رعاية األم الكنغر( في 34.9٪ من المرافق . وقد ارتفع هذا المعيار فى المستشفيات التى خضعت للتدريب الى ٪62.07 . 3- .يتم إعطاء المجال لألمهات العامالت بالمرافق إلرضاع أطفالهن رضاعة طبيعية أو إبقاء األطفال قريبين منهن أثناء العمل لتشجيعهن على مواصلة الرضاعة الطبيعية في 29.03٪ من المرافق الصحية . 4- كما أن األمهات المترددات على أطفالهن في الرعاية المركزة لألطفال يخصص لهن مكان لالرضاع ولتعصير الثدي في 61.3٪ من المرافق الصحية. الخطوة الثامنة : "تشجيع الرضاعة عند الطلب" 1- قامت 42.6% من األمهات بوصف اثنين على األقل من عالمات الجوع عند األطفال ولكن لم يتأثر هذا المعيار بالتدريب. 2- ذكرت 39.8٪ من األمهات أنه قد نص لهن باإلرضاع عند الطلب أى كلما رغب الطفل وللمدة التى يريدها دون قيود على العدد أو المدة.. وقد ارتفع هذا المعيار فى المستشفيات التى خضعت للتدريب الى ٪59.3 . الخطوة التاسعة : "منع اعطاء أية حلمات أو لهايات أو سكاتات ألطفال األمهات المرضعات". 1- بالمالحظة وجد أن 59.6٪ من األطفال ل يستخدمون زجاجة اإلرضاع و قد تحسن هذا المعيار بعد التدريب الى ٪84.5. 2- ذكرت 55.7٪ من األمهات المرضعات أن أطفالهن لم يتعرضوا إلى تغذية أو سوائل في زجاجات بحلمات أثناء الحجز فى مكان الوالدة. وقد ارتفع هذا المعيار فى المستشفيات التى خضعت للتدريب الى ٪84.5 . 3- ذكرت 60.6٪ من األمهات المرضعات أن أطفالهن لم يعطوا لهايات أثناء وجودهم في مكان الوالدة. وقد ارتفع هذا المعيار فى المستشفيات التى خضعت للتدريب الى ٪80.5.

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تحديد احتياجات المستشفيات الصديقة للطفل اإلدارة المركزية لرعاية األمومة والطفولة بوزارة الصحة منظمة األمم المتحدة لألطفال )اليونيسف( جمعية أصدقاء رعاية األم والطفل

الخطوة العاشرة : "تحويل األمهات عند الخروج من المستشفى الى الفئات أو األماكن التى توفر لهن الدعم المستمر" 1- أفاد الطاقم اإلداري فى 45.5٪. من المرافق الصحية بإعطاء معلومات لألمهات عن كيفية الحصول على الدعم إذا احتجن للمساعدة إلرضاع أطفالهن بعد العودة الى المنزل، وقد ارتفع هذا المعيار فى المستشفيات التى خضعت للتدريب الى ٪71.4. 2- أفاد 18.2٪ من المرافق بأنه يتبني مجموعات دعم األم أو غيرها من الخدمات المجتمعية التي تدعم األمهات فى الرضاعة الطبيعية و تغذية الرضع. وقد ارتفع هذا المعيار فى المستشفيات التى خضعت للتدريب الى ٪57.14. 3- العاملون الذين يشجعون األمهات على المتابعة في هذا المركز أو مركز قريب أومع شخص أو مجموعة دعم فى الرضاعة الطبيعية يشكلون 39.4٪. وقد ارتفع هذا المعيار فى المستشفيات التى خضعت للتدريب الى ٪71.4. 4- في 15.2٪من المنشآت التي تمت زيارتها يتم توزيع معلومات مطبوعة على األمهات قبل الخروج من أماكن المتابعة ، وقد ارتفع هذا المعيار فى المستشفيات التى خضعت لتدريب الى ٪42.85. 5- أكدت ثلث األمهات(%34.25)التى تم لقاؤهن أنهن قد أ ُعطين معلومات عن كيفية ومكان الحصول على المساعدة لتغذية أطفالهن بعد العودة للمنزل، وتمكن من ذكر نوع واحد من المساعدة المتاحة وقد ارتفع هذا المعيار فى المستشفيات التى خضعت لتدريب الى ٪47.7. الممارسات الصديقة لألم 1- لم تكن هذه الممارسات مدرجة في السياسة التي اتخذتها المستشفى لتصب صديقة للطفل. 2- أفاد 41.9٪ من الموظفين الذين تم مقابلتهم عن هذه الممارسات بصفة غير رسمية. 3- وصف 40.4٪ من الكادر الطبي اثنين على األقل من الممارسات الموصى بها التي يمكن أن تساعد األمهات على أن تكون أكثر راحة وتمكن أثناء المخاض والوالدة . 4- استطاع 48.5٪ من طاقم الوالدة سرد ما ال يقل عن ثالث إجراءات والدة ينبغي أال تستخدم بشكل روتيني ولكن فقط إذا اقتضى األمر بسبب المضاعفات . 5- وصف 45.8٪ من العاملين بخدمات الوالدة اثنين على األقل من ممارسات ما قبل الوالدة التي تضمن بداية جيدة للرضاعة الطبيعية. اللتزام بالمدونة ومتابعة تطبيقها وفقا لمعايير االلتزام بالمدونة، تم رصد ما يلي: 1- مندوبو الشركات المصنعة أو الموزعة لكل من بدائل لبن األم أو الزجاجات أو الحلمات أو اللهايات لم يكن لديهم أي اتصال مباشر أو غير مباشر مع السيدات الحوامل أو األمهات في 81.8٪ من المستشفيات التي تمت زيارتها. وقد ارتفع هذا المعيار فى المستشفيات التى خضعت للتدريب الى ٪89.3. 2- أدلى المسئول الصحى فى 69.7٪. من المستشفيات التي تم زيارتها أن األمهات ال يتلقين أي هدايا مجانية من الشركات المصنعة أو الموزعة ألي من بدائل لبن األم أو زجاجات

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تحديد احتياجات المستشفيات الصديقة للطفل اإلدارة المركزية لرعاية األمومة والطفولة بوزارة الصحة منظمة األمم المتحدة لألطفال )اليونيسف( جمعية أصدقاء رعاية األم والطفل

اإلرضاع أو الحلمات أو اللهايات ، وقد ارتفع هذا المعيار فى المستشفيات التى خضعت لتدريب الى ٪82.1. 3- أدلى المسئول الصحى فى 75.6٪ من المستشفيات أن المنشأة ال تقدم لألمهات وأسرهن موادا تسويقية أوعينات أو حزم هدايا تشمل بدائل لبن األم و زجاجات ولهايات ومعدات أخرى . وقد ارتفع هذا المعيار فى المستشفيات التى خضعت للتدريب الى ٪89.3. 4- خالل مراجعة السجالت وجد ان بدائل لبن األم بما في ذلك التركيبات الخاصة ولوازم التغذية األخرى يتم شراؤها من قبل مرفق الرعاية الصحية بأسعار الجملة أو أكثر في 48.5٪ من المستشفيات ،وقد ارتفع هذا المعيار فى المستشفيات التى خضعت للتدريب الى ٪53.6. 5- 72.7٪ من المستشفيات تمنع عرض وتداول المواد الترويجية لبدائل لبن األم وزجاجات اإلرضاع والحلمات واللهايات وكافة المنتجات األخرى المعنية طبقا للقوانين الوطنية، وال يتم عرضها أو توزيعها على السيدات الحوامل أواألمهات أو العاملين، وقد ارتفع هذا المعيار فى المستشفيات التى خضعت للتدريب الى ٪89.3. 6- يتم حفظ علب اللبن الصناعي وتحضير زجاجات اإلرضاع لألمهات غير المرضعات( بمنأى عن األم التى ترضع طفلها طبيعياً لمنع التأثير عليها في 63.4٪ من المستشفيات. وقد ارتفع هذا المعيار فى المستشفيات التى خضعت الى تدريب الى ٪71.4. 7- يستطيع 80.4% من مقدمى الخدمة من األطباء والتمريض ذكر أثرالتسويق التجارى الذى تقوم به الشركات ونتائجه السلبية على األمهات وعلى قدرتهن على اإلرضاع. ملخص نتائج المسح فى مراكز رعاية األمومة والطفولة : الخطوة األولى : وهى الخاصة بوضع ونشر السياسة الخاصة بدعم وحماية الرضاعة الطبيعية، وقد تراوحت النسبة من 44.2% الى 49.4% للمعايير األربعة األولى من هذه الخطوة ، وقد بلغ المعيار الخامس 28.6%، أى أنه ال يوجد آلية للمتابعة فى أكثر من 55 وحدة صحية من ال77 وحدة التى تم زيارتها. الخطوة الثانية : وهى الخاصة بتقييم آلية التدريب فقد تراوحت المعايير من 13% الى %26 ولألسف كان التحسن بعد التدخل بالتدريب ضئيال للغاية. الخطوة الثالثة : هى من صميم عمل مراكز رعاية األمومة والطفولة من حيث توعية األمهات والسيدات الحوامل بأهمية وكيفية اإلرضاع. وقد تراوحت المعايير من 15.6% الى 59.7% وكان التدنى األوض مالحظا ً في تعليم السيدات الممارسات الصديقة لألم وتعليم األم فوائد ممارسة مالمسة الجلد للجلد مع وليدها بعد الوالدة مباشرة وكيفية اإلعداد لذلك بالمالبس المناسبة .و قد تحسنت هذه المعايير بعض الشىء فى الرعايات التى خضعت للتدريب. الخطوة الخامسة : وهى الخاصة بتعليم مهارات االستيضاع والتعلق السليم وتعصير اللبن. وقد تراوحت المعايير التى تقاس بها هذه الخطوة فى مراكز الرعاية من 73.4% الى 91.3% ولم ترتفع فى الرعايات التى خضعت للتدريب مقارنة بمقابلتها التى لم تتعرض لتدريب. الخطوة السادسة : وقد تراوحت المعايير من 37.4% الى 91.2% ولم تتأثر بالتدريب.

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تحديد احتياجات المستشفيات الصديقة للطفل اإلدارة المركزية لرعاية األمومة والطفولة بوزارة الصحة منظمة األمم المتحدة لألطفال )اليونيسف( جمعية أصدقاء رعاية األم والطفل

استنتاجات وتوصيات

نستنت من هذه الدراسة ما يلي: اشتملت هذه الدراسة على عينة ممثلة من المستشفيات ومراكز صحة األم والطفل التي خضعت للتدريب على برنام المستشفى الصديق للطفل وفئة أخرى لم تتعرض لمدخالت هذا البرنام ، وتتركز الممارسات التى تحتاج الى تحسين على ما يلى: أولا: السياسة التى تشجع الرضاعة طبقاً للخدمات التى يقدمها المرفق وكيفية حماية الرضاعة غير مكتوبة بطريقة واضحة واستعاض الكثير منهم بعرض نموذج الخطوات العشر واعتبر البعض اآلخر هذا النموذج ملخصا لسياسة تشجيع الرضاعة الطبيعية على الرغم من وجود أمثلة للسياسات المختلفة حسب الخدمات المقدمة فى دليل التدريب. ثاني ا: ممارسة الجلد للجلد لمدة ساعة: على الرغم من أن هناك أدلة على أن بعض الممارسات الهامة تطبق بالفعل إال أن الطريقة التى تطبق بها قد ال تتوافق مع التوصيات المحدثة لبرنام المستشفيات الصديقة للطفل. فمثالً يقوم الطاقم الطبى بإعطاء الطفل لألم لرؤيته أو احتضانه فورا بعد والدته فى الوالدة الطبيعية أو القيصرية بدون تخدير كلي لمدة دقائق قليلة ولكن ليس لممارسة مالمسة الجلد للجلد على أمه لمدة ساعة كاملة أو لحين يبدأ المص على الثدي. ثالث ا: مساعدة األم فى طريقة اإلرضاع من حيث الوضعية والتعلق الجيد تم وصفها بطريقة صحيحة فى أغلب األحيان من قبل األطباء ولكن ليس بشكل مناسب من قبل الممرضات. رابع ا: مهارة تعصير الثدي لم يتم وصفها بشكل صحي من قبل معظم العاملين، سواء األطباء أو التمريض، بالتالي األمهات كن غير قادرات على تنفيذ ذلك ولجأن إلى استخدام مضخات القرن المطاط التي هي في غاية الخطورة ألنها يمكن أن تكون مصدراً للعدوى لألم والطفل وباألخص إذا تغذى من لبن األم الذي تم شفطه من خاللها. خامساا ا: الرضاااعة المطلقااة فااى الحضااانات: أظهىىرت الدراسىىة أن تشىىجيع الرضىىاعة الطبيعيىىة المطلقة عند الوالدة كان متعارف عليىة مىن قبىل جميىع أقسىام الىوالدة ومراكىز رعايىة األمومىة والطفولة ، ولكنه لألسف لم يكن هذا هو غير مفعل فىي وحىدة حىديثي الىوالدة ، حيىث يتعىرض األطفىىىال المحتجىىىزون بهىىىا للتغذيىىىة الصىىىناعية ألنىىىه ببسىىىاطة ال يسىىىم لألمهىىىات بالبقىىىاء فىىىي المستشفيات مىع أطفىالهن، وكانىت هنىاك صىعوبة فىي تواجىد األم بصىفة منتظمىة للرضىاعة أو تعصىىير اللىىبن، ولىىم يكىىن هنىىاك دالئىىل سىىريرية توجيهيىىة لألمهىىات أو العىىاملين لشىىرح طريقىىة تعصير اللبن. ولىم يكىن هنىاك إرشىادات عىن أهميىة لىبن األم للطفىل المبتسىر وأنىه أفضىل غىذاء لتلبيىة احتياجاتىه ويحميىه مىن عىدوى المستشىفى ويسىاعد علىى نمىو المىل بشىكل يجعلىه كالطفىىل كامل النمو حيث يحتوى على العناصر التى تدعم نمو المل اآلدمى وهى غيىر موجىودة فىى أى ألبان أخرى وال يمكن االعتماد على إضافتها ألنهىا ال تمىتص اال فىى المنىاب البكتيىري لألمعىاء الذى يوفره لبن األم.

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تحديد احتياجات المستشفيات الصديقة للطفل اإلدارة المركزية لرعاية األمومة والطفولة بوزارة الصحة منظمة األمم المتحدة لألطفال )اليونيسف( جمعية أصدقاء رعاية األم والطفل

سادس ا: فصل الطفل عن األم فى الحضانات: على الرغم من أن أقسىام الىوالدة تشىجع المسىاكنة فى عنابر ما بعد الوالدة وتسم بوجود األهل ولكن ذلك غير مفعل فىي وحىدة رعايىة األطفىال حديثي الوالدة. سابع ا: توجيه األمهات إلى عالمات رغبة فى الرضاعة: على الىرغم مىن أن الطىاقم الطبىى ال ينصىى األمهىىات بتحديىىد الرضىىعات ولكىىنهم لىىم يقومىىوا بتوجيىىه األمهىىات إلىىى عالمىىات رغبىىة الرضىيع فىى الرضىىاعة وأهميىة المالبىس الفضفاضىىة التىى تسىم بممارسىىة مالمسىة الجلىد إلىىى الجلد بارتياح مقارنة بالمالبس الضيقة التى كانت األمهات يرتدينها. مفهوم التوسع و التكامل فى البرنامج المحدث للمستشفيات الصديقة للطفل : اسىىىتهدف برنىىىام المستشىىىفيات الصىىىديقة للطفىىىل المحىىىدث والتكىىىاملى الموسىىىع إدمىىىاج هىىىذه الممارسىىات المحدثىىة فىىى جميىىع خىىدمات الرعايىىة الصىىحية والمستشىىفيات فىىي مختلىىف المنىىاطق ومختلف التخصصات وباألخص ممارسات فترة ما حىول الىوالدة مىن خىالل توحيىد السياسىات والممارسات فى فترة ما حول الوالدة . وعلى سبيل المثال كانت مهارة استيضاع وتعلق الطفل بالثدي موجودة وذكرها األطبىاء ولكىن لىيس التمىريض ويرجىع ذلىك لتىأثير برنىام الرعايىة المتكاملىة للطفىل المىريض .ويعىزى ذلىك مباشىىرة إلىىى التىىدريب ودمىى هىىذا البرنىىام فىىى مقىىررات طىىب األطفىىال بكليىىة الطىىب وكليىىة التمريض ولكن ليس في مدرسة التمريض. وكان من المتوقع أن برنام رعاية حديثي الوالدة سيؤثر على نشر الجزء الثاني من الخطوة الخامسة التى تلزم الطاقم الطبى بتعليم األم مهارة تعصير اللبن وكيفية الحفاظ على إدراره. ولكن هذا لم يكن واضحا من الدراسة. أيضا كان من المتوقع أن برام األمومة اآلمنة ستعمل على تشجيع البداية المبكرة للرضاعة من خالل مالمسة الجلد للجلد خالل الساعة األولى من الوالدة كاستراتيجية للحد من وفيات األمهات. ولكن مرة أخرى كان هذا غير مطبقا بالمستشفيات التي تم مسحها أو كان مطبقا بطريقة غير فعالة فى المستشفيات التى خضعت للتدريب من قبل برنام المنشآت الصديقة للطفل. أيضا كان من المتوقع أن برنام مكافحة العدوى سيكون قادرا ً على التأكيد على مالزمة األم للرضيع فى الحضانات وتشجيع الرضاعة عند الطلب وباألخص فى األيام األولى من حياة الطفل ووضع قواعد ودالئل لطريقة تعصير وحفظ اللبن ومنع استخدام زجاجات اإلرضاع واللهايات باعتبارها استراتيجية للحد من انتشار العدوى داخل المستشفى العدوى المكتسبة بالمستشفى(. وكان من النتائ اإليجابية التي بدت وكأنها تشق طريقها من خالل برام الرعاية المختلفة، وربما أيضاً من خالل برنام تنظيم األسرة هو االقتصار على الرضاعة الطبيعية من الوالدة وحتى ستة أشهر، وإن كانت ال تزال منخفضة، ولكن العديد من األطباء والممرضات ذكر أنها ممارسة روتينية وكانوا على علم تماما بأهميتها. ولكن كانت هناك بعض الرسائل المتضاربة الناشئة عن توزيع لبن الرضع بأسعار منخفضة لألمهات "المحتاجة" . ولألسف فإن زيادة وزن الطفل الفعلي ال يحدث إال بعد 3-2 أسابيع

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تحديد احتياجات المستشفيات الصديقة للطفل اإلدارة المركزية لرعاية األمومة والطفولة بوزارة الصحة منظمة األمم المتحدة لألطفال )اليونيسف( جمعية أصدقاء رعاية األم والطفل

وهذا يجعل األم تظن أن ليس لديها لبن كاف وباألخص قبل استخدام منحنيات النمو للطفل الرضيع، ولألسف فإنه حتى هذا اليوم-مازال الكثيرمن األطباء يتبعون المعتقد الخاطئ أن عدم استعادة الطفل وزن الوالدة فى األسبوع الثانى دليل على قلة اللبن، ويلجأ الطبيب حينذاك إلى إضافة لبن صناعى. وعلى النقيض فإن األم تحتاج الى الدعم في األسابيع الستة األولى وهو تماما ما نفتقر اليه. كما أظهرت نتائ البحث بالنسبة للخطوة العاشرة 10( أن جميع المستشفيات ليس لديها نظام تحويل مفعل يضمن لألم أن تواصل الرضاعة فى هذه الفترة الحرجة مع متخصصين يجيدون استخدام مهارات التواصل لدعم األم في مواصلة الرضاعة المطلقة. ولذلك تستهدف المبادرة المحدثة الى تكامل خدمات ما حول الوالدة بحيث تصب حزمة واحدة، فتقوى البرام بعضها البعض. وال يعنى ذلك ادماج برنام المستشفى الصديق للطفل فى البرام األخرى فحسب ولكن هناك ضرورة ألن يعمل كل برنام على حدى تكامل مع مقابله وباألخص على مستوى المستشفيات أو المراكز الطبية واالدارات الصحية فال تنفصل عند منفذ الخدمة ولكنها تكون مستقلة مركزياً الدارتها ومتابعتها وتقييمها على حدى. ويعتبر برنام المستشفى الصديق للطفل مكسبا قويا وفرصة استراتيجية لتقوية البرام األخرى وتعزيزها بالمهارات والممارسات التى تخدم مخرجات برامجها. فمثالً برنام مكافحة العدوى يستفيد من الخطوة 4 و7، في حين يستفيد برنام أمراض الطفولة المتكاملة من الخطوة 5 و8، وبرنام التحصين الموسع يمكنه االستفادة من الخطوة 6 والخطوة 8، في حين األمومة اآلمنة سوف تستفيد من الخطوة 3، وسوف يستفيد تنظيم األسرة من الخطوة 6 والخطوة 9، أما برنام األمراض غير المعدية فهو يستفيد من جميع الخطوات وتأثيرها على المدى الطويل على النتائ الصحية على األم والطفل. وبالتالي فإن التكامل هو وسيلة لتعزيز وتقوية البرام من خالل تعزيز الممارسات لتصب جزءا ال يتجزأ من النظام الصحي ويتحول إلى ثقافة وقيم تطبق تلقائياً ويتقبلها ويعتاد عليها العاملون والمترددون. والبد أن نقف وقفة عند الخطوة السادسة والمدونة الدولية حيث توصي كالهما بمنع وصف أو عرض أو توزيع أو إعطاء األطفال الرضع أية ألبان أخرى سوى لبن األم، وهى معايير يصعب قياسها فى ظل الظروف الخاصة بدعم األلبان وتوزيع اللبن المدعم من خالل المراكز الصحية، فالمعايير التى وضعتها المنظمات الدولية الصحية ال تتماشى على مثل هذا الوضع. وحتى فى حاالت الطوارئ فإن هذه األلبان تمن لألم واألطفال األكبر سنا وليس للرضيع حتى ال يحرم من لبن األم. ولذلك، وفى ظل ظروف الفقر التى يعانى منها بعض المناطق فى بالدنا فالبد من إعادة النظر فى األوضاع الراهنة وباألخص بعد أن ثبت فشل نظام ترشيد توزيع األلبان للفئات الخاصة وثبت تسربه إلى باقى الفئات. وتقوم شركات األلبان بممارسة كافة الضغوط واإلغراءات التي تصل لتقديم الرشاوى الستمالة أطباء األطفال - ونحن في موقف حرج حين نعرض هذه النتائ التى تظهر أنهم ملتزمون بالمدونة الدولية لمنع التسويق كل االلتزام بينما نعلم جيدأ ً أنه ال يتفق مع ما يتم على أرض الواقع... فنحن أمام مشكلة قيمية تحتاج إلى حلول عملية في الوقت الذي يعصف فيه نفوذ الرأسمالية العالمية ، ال رادع لها، والتى تستحل الترب على حسا مستقبل وصحة وحياة أطفال أبرياء نحن المسؤولون عنهم

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تحديد احتياجات المستشفيات الصديقة للطفل اإلدارة المركزية لرعاية األمومة والطفولة بوزارة الصحة منظمة األمم المتحدة لألطفال )اليونيسف( جمعية أصدقاء رعاية األم والطفل

أمام الديان! لماذا تتبنى مصر دون كل الدول هذا النظام الذى ال يطبق فى أى دولة أخرى متقدمة كانت أم نامية؟ وإلى متى سيستمر هذا الحال؟ كل ما نرجوه أن نلتفت بوعى إلى هذه السياسة ونطلب من المجالس التى تمثل الشعب أن يكون لديها الوعى والثقافة التى تمكنها من اتخاذ قرارات حكيمة بهذا الصدد، وأن يقفوا مع المسؤلين فى الصحة على وضع حد ونهاية لهذه الممارسات من الشركات وتوجيه الدعم الى األمهات بدالً من دعم ألبان األطفال تطبيقاً لتوصيات المنظمات الدولية بشأن توزيع األغذية والتعامل مع األزمات وامتثاالً بما فعله سيدنا عمر بن الخطا عندما صح قراره بصرف زكاة المال لألمهات التى أوقفن الرضاعة الى أن تصرف على جميع األمهات المرضعات بعد أن الحظ أن كثير من األمهات توقفن عن الرضاعة ليحصلوا زكاة المال، فالتاريل يعيد نفسه وتراثنا قدوة تماثل به علماء الغر فى وضع سياساتهم وتشريعاتهم فأين نحن من ذلك؟.

أخيراً عندما نشرع في وضع استراتيجيات للتدخالت من أجل تحقيق الصحة للجميع والوضع الغذائي األمثل فينبغي أن تكون النظرة أكثر شمولية لحل مشكالتنا الصحية والتغذوية من خالل اعتبار الجوانب التنموية األخرى مثل التعليم والصرف الصحي وظروف المعيشة والمشكالت االجتماعية التي يمثل التعليم وارتفاع معدالت األمية الشق األعظم منها. وفى تقرير وضع األمية وتعليم الكبارفى مصر 2008( بلغت نسبة األمية في المناطق الريفية 62٪ مقارنة 27٪ في المناطق الحضرية، وعالوة على ذلك فإن معدل األمية بين اإلناث أكبر من الذكور حيث تصل النسبة إلى 69٪ لإلناث و31٪ للذكور، ويبين توزيع معدالت األمية أن 40٪ يقعون فى الفئة العمرية األقل من 45عاماً و 55% فى الفئة العمرية ما فوق 45 عاماً ، وتعد األخيرة من أكثر الفئات تأثيراً على األمهات فى طريقة اإلرضاع وتمرير الممارسات الخاطئة فى تغذية الطفل، وعالوة على ذلك فإن واحدة من كل أربع من النساء األميات في سن اإلنجا ، وتزداد النسبة في المناطق الريفية وخاصة في ريف صعيد مصر حيث تعاني 3 من كل 4 نساء من األمية.

تشير هذه النتائ إلى أن حل المشكالت الصحية يحتاج إلى أن تؤخذ العوامل التنموية في االعتبار. وبالمثل فإننا ال يمكننا الوصول الى هدفنا المنشود من رضاعة طبيعية مطلقة فى الشهور الستة األولى واالستمرار بها لعامين كاملين بادخال أغذية كافية من الشهر السابع ....دون أن تكون هناك خطة موازية لتحسين وضع محو األمية والظروف السكانية لهؤالء السيدات.

البدء بالرضاعة الطبيعية فى الساعة األولى من الولدة من خالل وضع المولود على األم بعد تجفيفه مالمس ا الجلد للجلد وتركهما مع ا مع وجود مالحظ معهما حتى يهتدى ويرضع من الثدي بنفسه لتنبيه المراكز الهامة بالمخ التى تجعل التنفس ونبضات القلب تستقر ومراكز التحكم فى دلرجة الحرارة تتنشط فتمنع انخفاض درجة حرارته وتقوى الروابط العاطفية.

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