J. Pediatr. (Rio J.) vol.92 número5

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JPediatr(RioJ).2016;92(5):436---450

www.jped.com.br

REVIEW

ARTICLE

Impact

of

health

professional

training

in

breastfeeding

on

their

knowledge,

skills,

and

hospital

practices:

a

systematic

review

夽

Patricia

Carvalho

de

Jesus

a

_,

_Maria

_Inês

_Couto

_de

_Oliveira

b,∗

,

Sandra

Costa

Fonseca

b

a_Universidade_Federal_Fluminense_(UFF),_Instituto_de_Saúde_Coletiva,_Programa_de_Pós-Graduac_¸ão_em_Saúde_Coletiva,_Niterói,

RJ,Brazil

b_Universidade_Federal_Fluminense_(UFF),_Instituto_de_Saúde_Coletiva,_Departamento_de_{Epidemiologia}_e_{Bioestatística,}_Niterói,

RJ,Brazil

Received18June2015;accepted14September2015 Availableonline15February2016

KEYWORDS Breastfeeding; Healthprofessional; Training;

Knowledge;

Professionalpractice; Baby-Friendly HospitalInitiative

Abstract

Objective: Toidentifytheimpactoftraininginbreastfeedingonknowledge,skills,and profes-sionalandhospitalpractices.

Datasource: ThesystematicreviewsearchwascarriedoutthroughtheMEDLINE,Scopus,and LILACSdatabases.Reviews,studieswithqualitativemethodology,thosewithoutcontrolgroup, thoseconductedinprimarycare,withspecificpopulations,studiesthathadabeliefand/or pro-fessionalattitudeasoutcome,orthosewithfocusonthepost-dischargeperiodwereexcluded. Therewasnolimitationofperiodorlanguage.Thequalityofthestudieswasassessedbythe adaptedcriteriaofDownsandBlack.

Summaryofdata: Theliteraturesearchidentified276articles,ofwhich37wereselectedfor reading,26wereexcluded,andsixwereincludedthroughreferencesearch.Intotal,17 inter-vention articleswere included,threeofthem withgoodinternal validity.The studieswere performedbetween1992and2010incountriesfromfivecontinents;fourofthemwere con-ductedinBrazil.Thetrainingtargetpopulationswerenursingpractitioners,doctors,midwives, andhomevisitors.Manykindsoftrainingcourseswereapplied.Fiveinterventionsemployedthe theoreticalandpracticaltrainingoftheBaby-FriendlyHospitalInitiative.Allkindsoftraining coursesshowedatleastonepositiveresultonknowledge,skills,and/orprofessional/hospital practices,mostofthemwithstatisticalsignificance.

Conclusions: Trainingofhospitalhealthprofessionalshasbeeneffectiveinimproving knowl-edge,skills,andpractices.

夽 _Please_cite_this_article_as:_de_Jesus_PC,_de_Oliveira_MI,_Fonseca_SC._Impact_of_health_professional_training_in_{breastfeeding}_on_their

knowledge,skills,andhospitalpractices:asystematicreview.JPediatr(RioJ).2016;92:436---50. ∗_{Corresponding}_author.

E-mail:[email protected](M.I.C.deOliveira). http://dx.doi.org/10.1016/j.jped.2015.09.008

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Hospitaltraininginbreastfeeding 437

PALAVRAS-CHAVE Aleitamentomaterno; Profissionaldesaúde; Capacitac¸ão;

Conhecimento; Práticaprofissional; IniciativaHospital AmigodaCrianc¸a

Repercussãodacapacitac¸ãodeprofissionaisdesaúdeemaleitamentomaternosobre

seusconhecimentos,habilidadesepráticashospitalares:umarevisãosistemática

Resumo

Objetivo: Identificararepercussãodacapacitac¸ãoemaleitamentomaternosobre conhecimen-tos,habilidadesepráticasprofissionaisehospitalares.

Fontesdosdados: A busca darevisãosistemáticafoi efetuadanasbases MedLine,Scopuse Lilacs. Foram excluídos artigosde revisão, de metodologia qualitativa, estudos semgrupo controle, conduzidosnaatençãoprimária,comclientelasespecíficas,cujosdesfechoseram crençae/ouatitudeprofissionaletrabalhoscomfoconoperíodopós-altahospitalar.Nãohouve limitação quanto ao anoou idioma,sendorealizada avaliação daqualidadedos artigospor critérioadaptadodeDowns&Black.

Síntesedosdados: Nabuscadeliteraturaforamencontrados276artigoseselecionados37para leituraintegral,sendoexcluídos26artigoseincluídos6mediantebuscadasreferências.Foram incluídos17artigosdeintervençãoetrêsapresentaramboavalidadeinterna.Osestudosforam conduzidosentre1992e2010empaísesdecincocontinentes,sendoquatronoBrasil.O prin-cipalpúblico-alvodascapacitaçõesforamprofissionaisdeenfermagem,médicos,parteirase visitadoresdomiciliares.Oscursosdecapacitaçãoforamdiversos,cincointervenções empre-gandootreinamentoteórico-práticodaIniciativaHospitalAmigodaCriança.Todasasformasde capacitaçãoapresentaramalgumresultadopositivosobreosconhecimentos,habilidadese/ou práticasprofissionaisehospitalares,amaioriacomsignificânciaestatística.

Conclusões: Ascapacitac¸õesdeprofissionaisdesaúdequeatuamemhospitaistêmsidoefetivas emaprimorarconhecimentos,habilidadesepráticas.

Introduction

TheWorldHealthOrganization(WHO)1_and_the_Brazilian

Min-istryofHealth2_recommend_exclusive_{breastfeeding}_for_six

monthsand breastfeedingsupplemented withother foods

until2yearsofageormore.

However, health professionals’ lack of knowledge and

skills on breastfeeding and unfavorable attitudes toward

this practice3 _can _negatively _influence _the _{establishment}

and maintenance of breastfeeding,4 _with _lack _of

train-ing representing one of the causes for the inefficiency

of professionalpractice.5 _The _health _{professional’s}_role_is

toreinterpret thescientific discourse withtheclientele.6

Therefore, it is essential to have knowledge and clinical

skills inbreastfeedingcounseling,tobeabletoguideand

assistinbreastfeedingmanagement,whennecessary.7,8

Several studies show the need for specific and

peri-odic training in promoting, protecting, and supporting

breastfeeding, aiding in the encouragement and

sup-port of breastfeeding policies and protocols in health

institutions.7---9

Highstaffturnover---aswellaslackofmotivation,

avail-able resources, and time --- are factors that hinder the

trainingofthehealthcareteam.10

A review by Fairbank et al.11 _on _the _{effectiveness} _of

professionaltraining topromote the onset of

breastfeed-ing found increased knowledge of the staff, but did not

identifystatisticallysignificantchangesregardingtheonset

of breastfeeding. Another review12 _of _{interventions} _with

professionals,withthedurationofbreastfeedingasthe

out-come,concludedthattheevidencewasstillinsufficientand

recommendedthatstudiesreportintermediateoutcomesof

interventions,suchasprofessionalknowledgeandpractices.

The Baby-Friendly Hospital Initiative (BFHI) is a

strat-egythatstartswithawareness,training,andmobilizationof

healthcareprofessionalsworkinginhospitals with

obstet-ricbeds,aimingtoestablishrulesandroutinesfavorableto

thepracticeof breastfeeding.It waslaunchedin1990 by

theWHOandTheUnitedNationsChildren’sFund(UNICEF)

duringa meeting where the Declaration of Innocenti was

signed.13 _At _this _meeting, _global _goals _were _proposed

and the ‘‘Ten Steps to Successful Breastfeeding’’ were

established.13

Step2oftheBFHIreferstothetrainingofstafftoacquire

thenecessaryknowledgeandskillstoimplementthe

hospi-talnormsandroutinesinbreastfeedingand,thus,theBFHI

courseisboththeoreticalandpractical.14

No reviews were found that focused on the influence

of health professionals’training in breastfeeding ontheir

knowledge and practices. Considering the importance of

professional training to improve hospital practices

aim-ing toincrease breastfeeding rates, the objective of this

systematic review was to highlight the impact of

train-inginterventions on breastfeeding in health professionals

workinginhospitalsregardingtheirprofessionalknowledge,

skills,andpractices,aswellashospitalpractices.

Methods

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438 deJesusPCetal.

SystemOnline(MEDLINE),Scopus,andLatin Americanand CaribbeanHealthSciences(LILACS)databases.Thesearch was carried out in September 2014 and focused on the training of health professionals that worked in hospitals regardingbreastfeedingsupport.Thesearchstrategyusedin theMEDLINEandScopusdatabaseswas:breastfeedingand healthprofessionalsand(capacityortrainingoreducation) and(knowledge or professionalpractice) and(hospital or maternityhospital);andinLILACS:breastfeedingandhealth professionaland(trainingoreducation)and(knowledgeor skillor professionalpractice)andtheequivalentwords in Portuguese.

Thestudyinclusioncriteriawere:originalarticles repor-ting on breastfeeding training and its impact on the professionals’ knowledge, skills, practice, and/or hospi-tal practices. Qualitative methodology articles, studies lacking a comparison control group, review articles, studiescarriedoutintheprimaryhealthcarenetwork, stud-ieswhoseoutcomesexclusivelycomprisedtheprofessional’s belief and/or attitude, studies with specific populations suchaspreterminfants orHIV-positivemothers,and stud-iesfocusing onthe impact of training onthe duration of breastfeedingin the post-dischargeperiodwere excluded fromthesystematicreview.Therewasnolimitationonthe publicationyearorlanguage.

Abstract search was performed independently by two authors of this systematic review. At this phase, articles were excluded according to the study selection criteria. Incaseof discordanceregarding theabstract,theauthors optedtoreadthefulltext.

An additionalsearchwasperformed,based onthe ref-erencelistsofarticlesreadin full,toincreasesensitivity, thusidentifyingarticlesthatwerenotretrievedthroughthe electronicsearch.Afterreadingtheminfull,anew exclu-sionwascarriedoutaccordingtothesamestudyselection criteria. Disagreementswere resolved byconsensus or by consultationwithathirdreviewer.

Datawereextractedusingastandardizedformandthe final classification regarding inclusion in the review was alsoperformed independently;theresults werecompared anddisagreementsresolvedbyconsensusbetweenthetwo reviewers,withreferraltoathirdreviewerincasesof per-sistentdoubts.

Thearticleswerealsoindependentlyassessedregarding their quality, through a scoring system with a maximum scoreof20points.Theprotocolforassessingthequalitywas adaptedfromDownsandBlack,15 _and_consists_of₂₀

ques-tions:(1)Wasthehypothesis/objectiveclearlydescribed?;

(2)Werethestudyoutcomesclearlydescribedinthe

Intro-duction or Methods section?; (3) Were the characteristics

ofthepatientsincludedinthestudyclearlydescribed?;(4)

Werethe interventionsof interest clearly described?; (5)

Wasthe distributionof confoundingfactors ineach group

clearlydescribed?;(6)Werethemainfindingsofthestudy

clearlydescribed?; (7) Didthestudy provide estimates of

randomvariabilityofdataforthemainoutcomes?;(8)Are

thecharacteristicsofthelostpatientsclearlydescribed?;(9)

Werethe95%confidenceintervalsand/orp-valuesreported

for associations with major outcomes, except when the

p-valuewas<0.001?;(10)Werethesubjectsinvitedto

par-ticipateinthestudyrepresentativeofthepopulationfrom

whichtheywererecruited?;(11)Was therean attemptat

blindingsubjectssubmittedtotheintervention?;(12)Were

the statistical tests usedtoassess the significance of the

associations with the main outcome measures adequate?;

(13) Were the comparison groups maintained?; (14) Were

themainoutcomemeasuresaccurate(validandreliable)?;

(15) Were the groups to be compared obtained from the

same population?; (16) Werethe study subjects recruited

inthesameperiodoftime?;(17)Werethesubjectsinthe

intervention group randomized?; (18)Was thereadequate

adjustment for confounding factors in the analysis from

whichthemainfindingswereobtained?;(19)Werethelosses

tofollow-up takeninto account?; (20)Didthe studyhave

enoughpowertodetectasignificantclinicaleffect,inwhich

theprobabilityvalueforthedifferenceduetochanceisless

than5%?

Each question was scored with 0 (negative) or 1

(pos-itive). Considering the score achieved by each study, the

evaluateditemswereclassifiedaspoor(0---9points),

regu-lar(10---14points),orgood(15---20points).Articleswithpoor

qualitywereexcluded fromthereviewbecausetheywere

consideredtohavelowinternalvalidity.

Twotableswereconstructed,accordingtotheoutcome.

Thefirstshowsarticleswhoseassessedoutcomewere

pro-fessionalknowledge,skills,and/orpractice,andthesecond

showsarticleswhoseoutcomewerehospitalpractices.Both

professionaland hospitalpracticesin generalwere

evalu-atedusingtheTenStepstoSuccessfulBreastfeedingasthe

parameter(Table1).Thearticlesinvestigatingthetwo

out-comesareshowninTables2and3.

Thecolumnsofthetablesshow:thearticle’sfirstauthor,

year of publication, the place and year the study was

performed;qualityscoreobtained;thestudysetting,

pop-ulation, and sample size (or the number of participants

when the article does not specify the sample size); the

study design (studies in which therewasa randomization

processwereconsideredrandomizedcontrolledtrials;

stud-ieswithexternal controlgroupbutwithoutrandomization

wereconsideredquasi-experimentalstudies,andthosewith

internalcontrolgroupwereconsidered‘‘beforeandafter’’

interventions);theexposure;theassessedoutcomeandthe

evaluationmethod;and,finally,theobservedresults.Each

lineshowsanarticle,whichareshownbyyearofthestudy

(Tables2and3).

Theeffectof trainingwiththe TenStepstoSuccessful

Breastfeeding14 _on_the _hospital_practices_was_summarized

inthelastparagraphoftheresults,consideringtheeffect

aspositivewhenthechangesweresignificantorwhen100%

ofcompliancewiththeStepwasachieved.

Results

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Table1 Tenstepstosuccessfulbreastfeeding.

1 Haveawrittenbreastfeedingpolicythatisroutinelycommunicatedtoallhealthcarestaff. 2 Trainallhealthstaffinskillsnecessarytoimplementthispolicy.

3 Informallpregnantwomenaboutthebenefitsandmanagementofbreastfeeding. 4 Helpmothersinitiatebreastfeedingwithinhalfanhourofbirth.

5 Showmothershowtobreastfeedandhowtomaintainlactation,eveniftheyshouldbeseparatedfromtheir infants.

6 Givenewbornsnofoodordrinkotherthanbreastmilk,unlessmedicallyindicated. 7 Practiceroominginbyallowingmothersandbabiestoremaintogether24hoursaday. 8 Encouragebreastfeedingondemand.

9 Givenoartificialteatsorpacifierstobreastfeedinginfants.

10 Fostertheestablishmentofbreastfeedingsupportgroupsandrefermotherstothemondischargefromthe hospital.

thestudiesreadinfull,totaling17articlesincludedinthe review(Fig.1).

Of the 17 articles, nine addressed professional

knowledge,7,16---23 _two _professional _skills,7,24 _three

profes-sionalpractices,9,20,21_and_nine_hospital_practices.9,16,19,25---30

Thestudiesaddressedinterventionsthatwereclassified

asrandomizedcontrolledtrials(3),7,16,26_{quasi-experimental}

studies (5),9,19,20,23,24 _and _the _‘‘before _and _after’’ _type,

which used an internal control group (9)17,18,21,22,25,27---30

(Tables2and3).Resultsrelatedtobreastfeedingduration

afterhospitaldischargewerenotincludedinthisreview.

Thestudieswerecarriedoutbetween1992and2010in

several countries: four in Brazil,7,16,26,29 _one _in _Mexico,18

one in the United States,23 _one _in _Canada,9 _two _in _the

UnitedKingdom,22,24 _two_in_France,27,28 _one_in _Italy,19 _two

inCroatia,21,30 _one_in_Nigeria,20 _one_in _India,25 _and_one_in

Australia.17 _The _setting _of _these_studies _was_varied: _large

andsmallhospitals,of lowand highrisk, publicand

phil-anthropicinstitutions,in urban andruralareas. The main

target audience of these courses was nursing

profession-als/staff,physicians,andhomevisitors.

Thetrainingcourseswerediverse:theoreticaland

prac-ticalBFHI training14 _lasting _18---24_h _was _employed_in _five

studies,19---21,29,30 _while _two22,24 _used _a _{breastfeeding}

man-agementcourse,31_and_the_WHO_counseling32_course_lasting

40hwasusedinonestudy.7

Two studies used a Wellstart-SLC (Santos Lactation

Center)33_course_lasting₁₃₃_h,16,26_two_applied₃_day_courses

onthebenefitsandmanagementofbreastfeeding,27,28_one

appliedan 18-h theoretical---practical course on maternal

Medline 116 results

Lilacs 43 results Scopus

117 results

276 articles

203 articles

73 articles duplicated among the data bases

166 articles excluded after reading the title/abstract, as they did not meet the selection criteria

37 abstracts selected for full text reading

Excluded articles:

- Score <10 at quality assessment (1) - Qualitative studies (2)

- Other outcomes, such as start and duration of BF and EBF (7) - Studies without coupled intervention (9)

- Case report/editorial (4)

- Study population: students/primary care professionals (3)

Articles included through reference search (6)

17 articles included in the review

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Table2 Studiesontheimpactoftrainingofhealthprofessionalsontheirknowledge,skills,andpractices. Author(yearof

publication),place andyearof performance

Qualityscore Studysetting,

population,andsample size

Studydesign Exposurevariable Outcomeandmethod ofassessment

Results

Westphaletal.16

(1995)

Santos/SP/Brazil 1992---1993

Fair(13/20) •8publicor

philanthropichospitals: interventiongroup---4; controlgroup---4

•12trained professionals:3per hospital

ofinterventiongroup

•Randomized clinicaltrial (hospital randomization)

•Theoreticaland practicaltraining: Course

(Wellstart-SLC) lasting14days,133h, ofwhich1/3is practicaltraining

•Professionals1 knowledge:pre-and post-test(comparison throughscores)

•Knowledge

-Improvementintheinterventiongroup knowledgescores:

20.27(±7.41)→26.92(±2.10). (controlgroupnotassessed)

McIntyre17₍₁₉₉₆₎

Australia 1994---1995

Fair(12/20) •Southernmetropolitan regionofAdelaide

•65healthprofessionals

•Beforeand aftertype

•2workshopson advantagesand managementofBF, during2months

•Eachworkshopwas repeatedat3 differentoccasions

•Professionals’ knowledge: questionnaireswere self-administered beforethe1st workshopandafter the2nd(comparison throughscores)

•Knowledge

-Improvedprofessionals’knowledgescore: 73.7(±12.8)→88.5(±7.4)a

Reaetal.7₍₁₉₉₉₎

São

Paulo/SP/Brazil 1996

Good(15/20) •1publicmaternity hospital

•60health

professionals:20inthe interventiongroupand 40inthecontrolgroup

•Randomized clinicaltrial

•Theoreticaland practicaltraining: WHO/UNICEF40-h CounselingCourse, with8hofpractice

•Professionals’ knowledgeandskills: pre-test,post-test soonaftertraining (comparisonthrough scores)

Experimentalgroupvs.controlgroup:

•Knowledge

-Pre-test:6.23vs.6.06 -Post-test:8.35vs.5.54a

•Post-courseclinicalandcounselingskills

-Clinicalhistory:5.2vs.3.8a

-BFassessment:9.9vs.8.6a

-Nonverbalcommunication:22.2vs.17.7a

-Listeningandlearning:19.4vs.12.2a

-Confidenceandsupport:36.0vs.24.3a

Hernández-Gardu˜no &dela

Rosa-Ruiz18₍₂₀₀₀₎

Mexico 1996---1997

Fair(12/20) •1generalhospital

•140nursing

professionals(among152 eligible)

•Theoreticaland practicaltrainingin breastfeeding:18h, with1/3ofpractice

•Knowledge: self-administered questionnairebefore andsoonafterthe course(comparison throughscores,from 0to10points)

•Knowledge

107professionalsfrommother-child assistanceservices

5.3(±1.4)→7.6(±0.9)a

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Table2 (Continued) Author(yearof publication),place andyearof performance

Results

Cattaneo& Buzzetti19₍₂₀₀₁₎

Italy 1996---1998

Good(16/20) •8eligiblehospitals Group1:4hospitalswith 377trainedprofessionals (of536eligible):from 10/1996to

02/1997

Group2:3hospitals(1 loss)with194trained professionals(of237 eligible)from10/1997to 02/1998

•2669mother-child binomials(with L>2000g,withno admissionattheICU)

• Quasi-experimental (withbefore andafter component)

•Multipliertraining in24-hcourses (18h+2h

counseling+4clinical practice)thattrained groups1and2 throughthe18-hBFHI course

•Professionals’ knowledge: self-administered questionnaireat baseline(06/1996) andaftereach trainingcourse (comparisonthrough scores)

•Knowledge

Baseline→post-trainingofgroup 1→post-trainingofgroup2: -Group1:0.41→0.66→0.72 -Group2:0.53→0.53→0.75 (p-valuenotmentioned)

Owoajeetal.20

(2002) Nigeria 1997

Fair(13/20) •1tertiaryhospital,2 secondaryhospitals,and 13basicunitswith obstetriccare)

•298nurses(of305 eligibleprofessionals) workingforatleast6 months:113trainedand 185inthecontrolgroup

• Quasi-experimental (withprevious intervention)

•Theoreticaland practicaltraining: WHO/UNICEFBFHI 18-hcourse

•Knowledgeand professional practices: self-administered questionnaire (comparisonof knowledgeonEBF throughproportions andscores(0---20 points);about problemsand managementof problemsin breastfeeding throughproportions

•Knowledge

Experimentalvs.control:Onthe advantagesofEBF

-knowledgescoresof(11items):11.9 (±1.84)vs.10.7(±2.4)

-differenceonlyfordiarrheareduction: 97.3%vs.87.0%a

2.OncausesandmanagementofBF problems.

-effectofpre-dairy,a_sore_nipples,a

insufficientmilk,a_breast_engorgement,a

mastitis,a_management_of_neonatal

jaundice

•Professionalpractices

Experimentalvs.control -Step4(BFstart): 91.2%vs.81.6%a

-Step5(expressionbyhand):75.2%vs. 65.4%

-Step6(notusingpre-dairy):73.5%vs. 54.6%a

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Results

Martens9₍₂₀₀₀₎

Canada 1998

Fair(13/20) •2smallhospitalsin ruralareas.

•InterventionGroup:1 hospital,15of24eligible nursingprofessionals

•ControlGroup:1 hospital,16of19eligible nursingprofessionals

•Breastfedbabies:26in theinterventionhospital and23inthecontrol hospital

• Quasi-experimental

•Traininglasting 1.5hwithnurses duringworkhours andoptionaltutorial

•Focusonknowledge ofthemanagement ofBFandBFHIpolicy

•AdherencetoBFHI principles:

Self-administered questionnairebefore theinterventionand after8months (comparisonof proportions)

Interventionhospital:

-Step1:Informationonnorms:15%→87%a

-Step3:discussbenefitsofBF:60%→73% -Step4:offerhelptostartBFwithinthe 1sthour:75%→87%

-Step5:recordlatching/position: 45%→67%

-Step5:guideexpressionbyhand: 40%→73%a

-Step6:doesnotencourageuseof supplements:30%→67%a

-Step8:doesnotlimitBFondemand: 5%→7%

-Step9:doesnotrecommenduseof bottle:30%→67%a

-Step10:guidespost-dischargeBFsupport: 5%→67%a

Moranetal.24

(2000)

UnitedKingdom 1999

Fair(10/20) •4hospitals: 3experimentaland1 control

•13obstetricnurses evaluatedbeforethe courseand15afterthe course

•Trainingof WHO/UNICEF managementin maternalBF:20h

•Professionals’skills: analyzedthrough pre-validatedBeSST (Breastfeeding SupportSkillsTool) toolusingvideoclips. Questionnaireswere self-administered (comparisonof scores)

•Skills

Experimentalvs.control:

-SkillscoresinthemanagementofBF support:

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Results

Zakarija-Grkovi´c& Burmaz21₍₂₀₁₀₎

Croatia 2007---2009

Fair(12/20) •5largehospitals.

•308professionals trainedof424eligible (72.6%)

•Theoreticaland practicaltraining: WHO/UNICEFBFHI course:20h

•Professional knowledgeand practices:

Questionnaireswere self-administered beforethetraining (n=223)andafter 3months(n=213) (comparisonofhit ratios)

•Knowledge

DefinitionofEBF,a_time_of_first_BF,a_role_of

prolactin,a_signs_of_inadequate_positioning

forBF,a_hospital_support_practices,a_signs_of

inadequatelatching,barrierstoBF.

-RecommendationondurationofEBFa_and

BF,a_management_of_insufficient_milk

productiona_and_mastitis,a_adherence_to

ICMBMS,a_BF_{recommendation}_after

C-section,BFmanagementwhenthebaby refusestosuck

Wissettetal.22

(2000)

UnitedKingdom Yearnot mentioned

Fair(12/20) •1hospital

•22professionals: nursesandhomevisitors (pre-test:22and post-test:18)

•Trainingin WHO/UNICEF Maternal Breastfeeding management:20h

•Knowledge: self-administered questionnairebefore and8weeksafterthe course(comparison throughmedian scores,maximum:30)

•Knowledge

-Medianoverallscore: 17→24a

Bernaixetal.23

(2010) UnitedStates Yearnot mentioned

Fair(13/20) •12hospitals

•InterventionGroup:9 hospitals,203nurses(of 297eligibleones)

•ControlGroup:4 hospitals(with1loss), 34nurses(of64eligible)

•Tenmodulesof self-teaching materialtobe studiedfor4---6weeks beforethepost-test

•Knowledge: Self-administered questionnairewith 50items(comparison ofproportionsand meanscores)

•Knowledge

Experimentalvs.control: 64%→78%a_vs._61%_→_62%

31.9→39.2a_vs._30.5_→_31.7

BF,breastfeeding;EBF,exclusivebreastfeeding;BFHI,BabyFriendlyHospitalInitiative;WHO/UNICEF,WorldHealthOrganization/TheUnitedNationsChildren’sFund;ARF,acuterespiratory failure;ICMBMS,TheInternationalCodeofMarketingofBreastmilkSubstitutes.

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Table3 Studiesontheimpactoftrainingofhealthprofessionalsonhospitalpractices.

Author(yearof publication),place andyearof

performance,quality score

Qualityscore Studysetting,population, andsamplesize

Study design

Exposure variable

Outcomeandmethod ofassessment

Resultsonhospitalpractices

Westphaletal.16

(1995)

Santos/SP/Brazil 1992---1993

Fair(13/20) •8publicand

philanthropichospitals: interventiongroup---4; controlgroup---4

•12professionalstrained: 3perhospitalintervention

•Theoreticaland practicaltraining: Course

(Wellstart-SLC) lasting14 days,133h,with 1/3practical training

•AdherencetoBFHISteps 1---10:interviewswith managers,health professionals,pregnant women,andmothers beforeandsixmonths aftertraining

•Differencesininstitutionalscoresby hospitalpairs(experimentalorcontrol): Pair1:0.6vs.0.9;Pair2:1.6vs.−0.7 Pair3:1.9vs.0.2;Pair4:0.5vs.0.2

•Institutionalchanges:significant advanceinSteps1,2,10(p-valuenot stated)

Prasad&Costello25

(1995) India 1992---1993

Fair(13/20) •1publichospitalinthe countryside

•HospitalAdministrators, 8physicians,1wardsister, 9nurses

•Mother-childbinomials withnormaldeliveryand healthybabies(172at baseline,195soonafter theintervention,and101 sixmonthslater)

•Beforeand aftertype(with comparison between exposedand non-exposedsix months post-intervention)

•≥5individualor groupsessionswith healtheducation doctorsonSteps4 and6

•Changesinhospital practicesrelatedtoSteps 4and6:Mothers interviewedathometwo weeksafterdelivery(at baseline,soonafterthe interventionandsix monthspost-intervention)

Baseline→soonafterthe intervention→6months post-intervention

Mothersexposedtohealtheducation: 0%→100%→36%

-Step4:BFwithinthe1sthouroflife: 3%→60%→14%

-Step6:useofsupplements: 96%→43%→77%

(bothsignificantadvances,butp-value isnotmentioned)

Sixmonthspost-intervention: -Step6:useofsupplements: 42%(ofexposed,n=36)vs.97%(of non-exposed,n=65)a

Taddeietal.26₍₂₀₀₀₎

Santos/SP 1992---1993

Fair(14/20) •8publicorphilanthropic hospitals:intervention group---4;controlgroup ---4

•12trainedprofessionals: 3perinterventionhospital

•Mother-childbinomials: 494of609eligible (pre-training)and469of 555eligible(post-training)

•Theoreticaland practicaltraining: 14-day,133-h course (Wellstart-SLC course),with1/3 practice

•Changesinhospital practicesregardingSteps 4,5,and7:interviewto mothersduringhome visits(oneandsixmonths afterdelivery)

•Before/after,exposedvs.

non-exposed:

-Step4:BFinthedeliveryroom: 2%→23%a_×_2%_→_8%a

-BFwithinthefirst6h: 41%→53%a _×_48%_→_50%

-Step5:BFsupportatthehospital: 48%→64%a_vs._58%_→_61%

-Step5:BFsupportatthehospital: 29%→49%a_vs._35%_→_36%

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Hospital

training

in

breastfeeding

445

Table3 (Continued)

Study design

Exposure variable

Cattaneo&Buzzetti19

(2001) Italy 1996---1998

Good(16/20) •8eligiblehospitals Group1:4hospitalswith 377trainedprofessionals (of536eligible)from 10/1996to02/1997 Group2:3hospitals(1 loss)with194trained professionals(of237 eligible)from10/1997to 02/1998

•2669Mother-child binomialswith

BW>2000g,withoutICU admission

• Quasi-experimental (withbeforeand after

component)

•Multipliertraining in24-hcourses (18h+2h counseling+4 clinicalpractice) thattrainedgroups 1and2usingthe BFHI18-hcourse

•AdherenceBFHITen Steps:Self-administered questionnaireby professionals(steps1and 2),interviewtomothers preandpost-evaluation (Steps4---10)

Baseline→post-training

•Before/after--- overallresult: -MeanadherencetotheSteps: 2.4→7.7steps(p-valuenotmentioned)

•Before/after--- group1andgroup2: -EBFatdischarge:41%→77%and 23%→72%(p-valuenotmentioned) -Step4:BFwithinthe1sthour: 12%→22%a_and_37%_→_60%a

-Step5:latching/positioning: 67%→88%a_and_77%_→_93%a

-Step5:expressionbyhand: 60%→75%a_and_43%_→_72%a

-Step6:useofsupplements: 35%→17%a_and_8%_→_8%

-Step7:roomingin: 72%→89%a_and_36%_→_77%a

-Step8:BFondemand: 83%→97%a_and_97%_→_99%

-Step9:useofbottle: 58%→14%a_and_70%_→_26%a

-Step9:useofpacifier: 56%→19%a_and_63%_→_52%a

•LessadvancementinSteps1,2,and 10(p-valuenotmentioned)

Durandetal.27₍₂₀₀₃₎

France 1997---2000

Fair(11/20) •1tertiarymaternity hospital

•All73professionalsfrom thestaff

•Mother-childbinomials withoutICUadmission:50 beforethetraining programand50after (with71.4%ofresponse rate)

•Three-day theoreticaland practicaltraining onthebenefitsand managementof breastfeeding (10professionals perclass)from 1998to2000

•Changesinhospital practicesrelatedtoSteps 4---7,9,10:assessmentof newborns’recordsand self-administered questionnaire,givento mothersatthetimeof hospitaldischarge

•Accordingtomedicalrecord: -Step4:BFwithinthe1sthour: 7.9%→21%

-Step6:useofsupplements: 82%→63%

-Step7:mother-childseparation>4h: 52%→13%a

-Step9:formulaonlyincup: 0%→13.1%a

-Step9:useofbottle: 82%→26%a

-EBFatdischarge:14%→28%

•Accordingtothequestionnaire: -Step5:teachpositioningfor breastfeeding:41.7%→69.2%a

-Step10:post-dischargesupport resources:

(11)

446

de

Jesus

PC

et

al.

Study design

Exposure variable

Labarereetal.28

(2003) France 1997---2000

Fair(14/20) •1tertiarymaternity

•All73professionalsof thestaff

•Mother-childbinomials withoutICUadmission: 323(pre-training)and324 (post-training)

•Three-day theoreticaland practicaltraining onbenefitsand managementof breastfeeding (10professionals perclass) from1998to2000

•Changesinhospital practicesregardingSteps 4---7,and9:assessmentof maternalmedicalrecords beforeandaftertraining retrospectivelybynurse notinvolvedinassistance

EBFatdischarge:15.8%→35.2%a

-Step4:BFwithinthe1sthouroflife: 9.2%→16.9%a

-Step6:useofsupplements: 77.6%→54.0%a

-Step7:roomingin: 56.6%→72.6%a

-Step9:

formulainthecup:0.4%→23.8%a

useofbottle:77.2%→14.1%a

Martens9₍₂₀₀₀₎

Canada 1998

Fair(13/20) 2smallhospitalsinrural areas

•InterventionGroup:1 hospital,15of24eligible nursingprofessionals

•ControlGroup:1 hospital,16of19eligible nursingprofessionals

•Breastfedbabies:26in theinterventionhospital and23inthecontrol

•1.5-htraining withnursesduring working

hours+optional tutorial

•Focuson knowledgeofBF managementand BFHIpolicy

•AdherencetoBFHIand Steps1,2,6,7,9,and10 bythehospital:

Self-administered questionnaireby professionalsbeforethe interventionand8months after.

•EBFduringhospitalstay: assessmentofnewborn’s medicalrecord

(intervention:13preand 13post;control:14pre and9post)

•Accordingtothequestionnaire: Interventionhospital:

-Step1:writtennorm:40%→87%a

-Step2:skillsinBFmanagement: 35%→60%

-Step6:non-useofsupplement: 45%→87%a

-Step7:roomingin:90%→100% -Step9:non-useofbottle: 30%→67%a

-Step9:non-useofpacifier: 50%→67%

-Step10:encouragesupportgroups: 5%→47%a

•Accordingtomedicalrecords: experimentalvs.control-Adherenceto BFHI:

24.4%→31.9%a_×_20.2%_→_22.5%

-EBFduringhospitalstay: 31%→54%a_×_43%_→_0%a

Coutinhoetal.29

(2005) Pernambuco 1998(previous cohort)and2001

Fair(13/20) •2hospitalsfromSUS

•42professionalstrained (90%ofmidwivesand nurseaids)

•334mother-child binomialsof364eligible ones(2001)comparedto 364(1998).Urbanarea, singlebirth,withBW

≥2500g,healthy

•Beforeand aftertype (historical control)

•Theoreticaland practical training:18-h WHO/UNICEF-BFHI course+2hof breastfeeding counselingand educational material

•AdherencetoSteps4to 9ofBFHI:interviewwith mothersinthefirst48h and10daysafterdelivery.

historicalcontrol→experimentalgroup -Step4:

Skin-to-skincontact:25.8%→37.2%a

HelpwithBFatbirth:5.8%→6.0% -Step5:latching/positioning: 9.6%→21.0%a

-Step6:EBFwithinthe1st48h: 21.2%→70.0%a

-Step9:useofpacifier: 47.2%→24.3%a

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breastfeeding

447

Study design

Exposure variable

Zakarija-Grkovi´c etal.30₍₂₀₁₂₎

Croatia 2008--- 2010

Good(16/20) •1tertiaryhospital

•Trained80%ofthe271 staffprofessionals

•Mother-childbinomials (388pre-trainingand385 post)withBW>2500g, withoutICUadmission, singlebirths(interviewed 94.2%ofeligible)

•Theoreticaland practicaltraining: 20-h

WHO/UNICEF-BFHI course:oneclassin May2008and anotherinFebruary 2009

•AdherencetoSteps3to 9ofBFHI:assessmentof newborn’smedicalrecord; interviewwithmothers preandpost-training

•Accordingtothemedicalrecord:

-EBFwithin48h:6.0%→11.7%a

•Accordingtotheinterviews:

-Step3:recommendationsonchild feeding:10.8%→9.9%

-Step4:heldthebabyatthe1st contactfor>60min:0.8%→3.2%a

-Step4:babysuckedatthe1st contact:8.6%→4.2%

-Step5:helpwithlatching/positioning: 70.3%→69.0%

-Step5:wasshownexpressionbyhand: 44.1%→44.8%

-Step6:useofsupplements: 81.1%→79.4%

-Step7:roomingin: 0.3%→5.1%a

-Step8:BFondemand: 21.1→29.3%a

-Step8:durationondemand: 17.5%→28.6%a

-Step9:useofbottle:79.0%→77.8% -Step9:useofpacifier:0.3%→0%

BF,breastfeeding;EBF,exclusivebreastfeeding;BFHIBaby-FriendlyHospitalInitiative;BW,birthweight.

(13)

448 deJesusPCetal.

breastfeeding,18 _one_study_applied_a_night_workshop,17_one

useda1.5-h trainingcomplementedby tutorialmaterial,9

oneusedmaterialforself-learning,23 _and_one_study_used_a

methodologycomprisingfivediscussionsessionswitheach

professional.25

Theoutcomedefinedbyninestudieswasthe

profession-als’ knowledge of breastfeeding,two studies investigated

thecapacityofprofessionalsincounselingandmanagement

ofbreastfeeding,threeinvestigatedprofessionalpractice,

andnineinvestigatedhospitalpractices,usuallyregarding

adherencetotheBFHIsteps.

Asfortheevaluationmethod,twelvestudiesevaluated

theeffectoftrainingthroughinterviewsor questionnaires

that were self-administered by health professionals, six

evaluated through an interview or a questionnaire that

was self-administered by the mothers, one reported the

observation of the maternity areas, and three performed

a retrospective evaluation throughthe analysis of

mater-naland/orneonatalmedicalrecords.Regardingthetypeof

analysis,most studies performed only comparative

analy-sesusingstatisticalsignificancetests7,9,16---18,20---23,25---27,29_and

threeusedmultiplelogisticregressionanalysis.19,28,30

Regarding the quality assessment, three studies were

classifiedashavinggoodinternalvalidity,7,19,30 _whereas₁₄

wereclassifiedasfair.9,16---18,20---29

In the nine studies that investigated knowledge, the

intervention showed positive results. Five studies

mea-suredgain of knowledge through general scores, andone

by specifying the factors that achieved improvement. In

twostudies,21,24_the_{professionals}_were_trained_through_the

theoretical and practical training of BFHI14 _with _a

dura-tion of 20h, one with a duration of 18h,20 _one _through

the WHO counseling course32 _lasting ₄₀_h,7 _one

interven-tion trained multipliers using the Wellstart-SLC16 _133-h

course,33 _one _applied _the _18-h _theoretical _and _practical

courseonbreastfeeding,18_one_study_used_workshops_applied

during the night shift,17 _and _one _provided _material _for

self-learning.23_A_superior_effect_was_not_identified_in

inter-ventionswithlongerduration.

Only two studies investigated the effect of

train-ingthroughbreastfeeding counseling31 _and_management32

coursesontheprofessionalskills, withonestudy

discrim-inating the gains in listening and learning, and building

confidence and giving support,7 _and _another

demon-strating the achieved advances through mean scores.24

Threestudieshadprofessionalpracticesasoutcome,9,20,21

with gains being observed only in part of the practices

(Table2).Nine studies9,16,19,25---30 _evaluated_the _changes_in

hospital practices, obtaining advances in most of them

(Table3).

Asfortheresultsoftrainingonhospitalchangesrelated

tothe TenSteps,14 _the_object _of_nine_studies, _Step₃ _was

the least assessed, by only two investigations, with no

effect.16,30 _Steps _1, _2, _and ₈ _were _also _scarcely

investi-gated, by only three studies,9,16,19 _with _positive _changes

being achieved in two-thirds of interventions for Steps 1

and 8 and in one-third for Step 2. Step 10, assessed in

fourinterventions,9,16,19,27_showed_advances_in_three._Step_5,

assessedinsixstudies,16,19,27,29,30 _reached_positive_changes

intwo-thirdsoftheinterventions.Thetraininghadapositive

effectonfiveoftheseveninterventionsthatassessedStep

79,16,19,26---28,30_and_Step_9.9,16,19,27---30_Steps₄16,19,20,25,27---30_and

69,16,19,25,27---30_were_the_most_often_assessed,_in_eight_studies

each,showingfavorablechangesin75%(Step4)and62.5%

(Step6)oftheinterventions(Table3).

Discussion

Thestudiesincludedinthisreviewshowedpositiveeffects of trainingonthe assessedoutcomes:professional knowl-edge,skills,andpractices,aswellashospitalpractices.

The studies were carried out in different contexts, in developed and developing countries on five continents (America,Europe,Africa,Asia,andOceania).Thisdiversity seemstoindicatethatindiversescenarios,thecoursesused wereatleastpartiallyeffective,despiteeconomic,ethnic, andculturaldifferences.

Alltrainingmethodsemployed,regardlessofthemodel, duration, and target audience, showed increase in the knowledgeandskillsofhealthprofessionalsin breastfeed-ing,withnodose-responseeffectobservedinthissystematic review for the number of class-hours and the obtained effect.Benefitsforprofessionalandhospitalpracticeswere also observed; however, the interventions did not always achieve changes regarding the ‘‘Ten Steps to Successful Breastfeeding’’.

Steps1---3,8,and10weretheleastinvestigated.Among them, Step 2 (train the entire health staff) and Step 3 (inform pregnant women) showed fewer positive results. Possibly,thelowerperformanceinStep2isduetotraining programsthatdidnotincludeallprofessionalcategories,in additiontostaffturnover,whichimpairsthepermanenceof trainedstaff.34

Asfor Step 3,the prenatalclinic is veryoften located

outside the hospital complex, and the professionals that

provide prenatal care are not the same asthose working

in the maternity hospital. This hinders their involvement

with the BFHI and the investigation of adherence to this

Step.35 _It _is _worth _mentioning _the _importance _of

provid-inginformationtopregnantwomenaboutthebenefitsand

managementofbreastfeeding,asmostwomendefinetheir

intentiontobreastfeedduringpregnancy,36_which_influences

theonsetand durationofbreastfeeding.37 _In_a_study _that

nationallyre-evaluatedadherencetotheTenStepsin 167

Brazilian BFHI accredited between 1992 and2000, Araujo

andSchmitz10_also_found_lower_adherence_to_Steps₂_and_3.

Step1 (written norm) and Step 8 (stimulus to

breast-feedingondemand)obtainedpositiveresultsintwo-thirds

oftheinterventions, indicatingthatthetrainingprograms

maybeusefulforthedisclosingoftheinstitution’s

breast-feedingpolicyandfortheencouragementofbreastfeeding

ondemand.InBrazil,in SaoPaulo38 _and_Rio_de_Janeiro,35

little restrictionwas observed regarding thefree interval

between feedingsin publicandprivatehospitals, showing

goodadherencetothisprocedure.

The training alsoshowed to be effective in promoting

improvements in the practice of Step 10 (post-discharge

support) inthree-quartersofthe interventions,whichis a

relevantresult,consideringthedifficultiesfoundincarrying

outthisstepindifferentBrazilianscenarios.29,35

Steps4---7, and9, which arebasically hospital-related,

were more often investigated; the training programs

(14)

(helpinitiatepostpartumbreastfeeding),oneofthemajor

barriers to breastfeeding at birth has been cesarean

delivery,39 _which_is _on _the_rise _in _the _Brazilian _context;40

itisimportantthatprofessionalsareabletostimulate

skin-to-skincontactandearlysuctioneveninbabiesbornthrough

C-section.

Regarding Step5 (managementofbreastfeeding),

ade-quatemanagement of breastfeeding depends not only on

theoreticaltraining,butalsotheacquisitionofskillsbythe

healthprofessionalthatassistsmothers.Mostofthetraining

programsstudied inthisreviewwereboththeoreticaland

practical,whichmayhavecontributedtothepositiveresults

achievedby75%oftheinterventions.Advancesin62.5%of

theinterventionsregardingtheStep6(notofferthe

new-bornotherfoodsordrinksratherthanbreastmilk)suggest

that, despite its difficult adherence due tothe pressures

ofinfantformulaindustrymarketing,hospitalroutineshave

advancedsignificantly.10,35,41

The positive results observed in more than70% of the

studiesinvestigatingStep7(roomingin)indicatesevolution

inthestructureandroutineofhospitals,becauseroomingin

dependsnotonlyonprofessionaltraining.26_Regarding_Step₉

(notusingartificialnipplesorpacifiers),theuseofpacifiers

andbottlesmaypreventtheadequatedynamicofsucking

thenipple-areolaregionandreducethefrequencyof

feed-ingsand,thus, thereductionobservedin theuseofthese

artifactsinmorethan70%ofthestudiesthatinvestigated

themisextremelybeneficial.

Astudy conductedin theUnitedStates42 _demonstrated

thatSteps4,6,and9wereassociatedwithlongerdurationof

breastfeedingandthatmothersexposedtoatleastsix

hospi-talpracticesrecommendedbytheBFHIhada13-foldhigher

chanceofmaintainingbreastfeeding,comparedtomothers

whodid not have contact withany of the practices. The

observeddose-responseeffectindicatestheimportanceof

trainingprogramsaimedattargetaudiences,suchas

health-careprofessionalsfromvariousprofessionalcategoriesand

working in the different areas assisting pregnant women,

mothers, and babies,so that hospital practices coalesce,

resultinginasynergisticeffectonthedurationof

breast-feeding.

Regardingthelimitationsfoundinthissystematicreview,

theauthorsemphasizethedifferencesinthetraining

pro-gramsusedindifferentstudiesregardingtheduration,type,

and target audience, making it difficult to identify the

mosteffectivemethods,duration,andcontenttogenerate

changes in knowledge, skills, and professional and

hospi-talpractices.Thelack ofahomogeneousmethodofstudy

analysis,whichwouldfacilitatethecomparisonof results,

hindered the calculation of summary measures by

meta-analysis.

Another limitation found was the absence of a

homo-geneousanalysis methodamongthe studies, which would

facilitate comparison of the results. The studies had

different epidemiological designs, and the absence of

experimental studies indicates a higher risk of bias and

uncontrolled confoundingvariables.The evaluationof the

articles through the quality score showed fair quality in

mostarticles,butonlythreeshowedgoodinternalvalidity.

Theretrospectivedatacollection(fromrecords)wasalsoa

limitingfactorinsomestudies,27,28 _caused_by_the

possibil-ityof informationbiasduetoerror or theabsencein the

datarecording.Moststudiesdidnotmentionthe

represen-tativenessofthesample thatwasselectedandsubmitted

toevaluation.Mostpoorlysummarizedanddescribedtheir

results,hinderingthepresentation ofresultinterpretation

anduniformity.

Theshortperiodbetweeninterventionsandevaluations

usedinmoststudiesdidnotallowverifyingwhetherchanges

inprofessionalknowledge,skills,andpractices,aswell as

inhospitalpractices,canpersistinthelongtermafterthe

interventions.21,30_Factors_such_as_staff_turnover_and_policy

changescouldinterferewiththeresultsofevaluations

car-riedoutafterlongerpost-trainingintervals.Tomaintainthe

impactofthesetrainingprograms,itisnecessarytoreapply

themperiodically.7

Informationonthecontextoftheinterventions,onthe

availabledataforevaluation,andonthecost-effectiveness

of the employedtraining programswas sparse or absent,

whichreduces the possibilityof reproducing the research

along similar lines tothose undertaken in other settings.

Thisinformationcouldbeofgreatvalueforhealthfacility

managersandforfuturestudies.

Despite these limitations, the results of this review

demonstrate that the training of health professionals in

breastfeeding promotion brings improvements in

knowl-edge,skills,andpractices,evenwhenthetrainingdoesnot

followtheWHO/UNICEFstandards.

As foradherence totheTenSteps,the evidencefound

inthereview waslessconsistent.Itmustberecalledthat

thesepracticesdependnotonlyonprofessionaltraining,but

alsoonadministrativemanagementsupportforinstitutional

changes.21

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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