1- Formulation of a committee to ensure compliance with the Code standards and monitor Code violations at the hospital
Facilitator:
All participants have agreed that the breastfeeding committee at the hospital have ensured the adherence to the ‘code’ standards and controlled for any violations.
2- Setting criteria for calculation of fair market breast milk substitutes (BMS) prices and purchases for medical reasons.
According to all participants in the private hospital, hospital’s management has ensured the adherence to the ‘code’ BFHI standards and prevented any possible violation by enforcing policies prohibit the purchase of Breast Milk Substitutes (BMS) even for medical conditions and physician's prescribed formula for medical conditions are purchased by family members from outside the hospital. On the other hand, four participants in the governmental hospital classified the governmental BMS purchasing and supplying system for public hospitals through central warehouses as facilitator for the compliance with BFHI standards. However, few participants considered this system as a barrier since the BMS provided by the central warehouse do not always fulfill the newborns’ medical/nutritional needs.
Implemented strategy:
Unsuitable BMS lead family members to purchase a different formula based on physician's prescription in the governmental hospital.
3- Hospital’s policies and procedures regarding donations of free or subsidized (funded) supplies of breast-milk substitutes (BMS) by infant formula companies and ability to self-purchase of BMS for medical reasons.
Facilitator:
All participants noted that even before the BFHI adoption, the policies at the private hospital forbade any support from formula companies regarding BMS free donation or funding hospital's upgrading projects. This has facilitated the adherence to BFHI standards concerning the relationship with formula companies.
One administrative officer mentioned that: “the formula companies used to constantly offer funded supplies of BMS and upgrading projects however, hospital's values forbid the acceptance of any support/donation from formula companies that might compromise the best medical advice for mother/baby - hospital's slogan is "patients first"”.
Barrier:
At the governmental hospital, Formula companies had fully supported the free supply of different types of formulas according to hospital’s formula specifications (ready-to- feed, several types of formula for different medical conditions, etc…) as well as funding hospital’s refurbishing projects and provision of equipment. This formulated a major barrier for hospital’s management to fulfill the BFHI standards concerned with formula companies.
Implemented strategy:
In order to overcome this barrier, the hospital enforced new policies that prohibit free or funded BMS and that the supply of basic formula is through central governmental warehouse. In addition, the participation of the initiative included provision of equipment and staff training for breast milk collection and storage and BMS preparation in neonate unit instead of using ready-to-feed formulas donated by formula companies.
However, the basic formula provided by the central warehouse does not always meet all the different medical needs leading parents and family members to purchase prescribed BMS.
Two participants also stated that after the implementation of BFHI in the hospital, there is no need for BMS as mothers were encouraged to breastfeed.
4- Hospital’s policies and procedures concerning the contact of formula companies with mothers/family members and distribution of mother gifts and free samples
Facilitator:
The private hospital's policies forbid any contact of formula companies with mothers/family members even before the BFHI adoption; this has facilitated the encouragement of breastfeeding without the interference of formula companies according to most participants.
Barrier:
All participants at the governmental hospital classified this factor as a barrier as most formula companies insisted on approaching mothers and family members to encourage the use of BMS before and at the beginning of the BFHI adoption and implementation. They also constantly distributed free gifts to newborns and offered free or discounted supplies of BMS for some families (humanitarian cases) as part of companies' social
responsibility. Some hospital's staff members (midwives and nurses) used to give mothers and relatives the numbers of formula companies for free or at reduced-price of BMS supply or gifts.
Only one participant at the private hospital indicated that “despite the fact that the policies forbidding the contact of formula companies with mothers existed before the initiative, there were several violations from staff members”.
Implemented strategy:
After BFHI adoption, the private hospital utilized a strict policy enforcement approaches and imposed zero-tolerance policies for any violations.
The governmental hospital's new policies against contact of formula companies were generalized among all clinical and non-clinical staff (e.g. clinical staff members were prohibited from providing mothers any contacting information with these companies, and security banned the entrance of representatives from these companies to enter the hospital).
5- Presence of advertisements and promotional materials throughout the healthcare advertising of breast-milk substitutes and other products to the public contradicting with BFHI standards and visibility of breastfeeding or infant feeding written policy and posters
Barrier:
The majority of participants in both hospitals considered the presence of advertisements and promotional material encouraging the use of BMS hindered the promotion of breastfeeding among mothers.
The rest of participants (4) considered this factor as influential since such promotional materials were removed after adopting BFHI standards
Implemented strategy:
The breastfeeding committees in both hospitals removed all posters from infant formula companies and put the BFHI relevant posters encouraging breastfeeding (hospital's policy, breastfeeding and infant feeding, etc…).
6- Staff attitudes influenced by formula companies through sponsored trips and conventions, free samples, gifts, etc…
Facilitator:
Most participants in the private hospital indicated that hospital's policies prohibited any collaboration with formula companies and hospital's senior management (especially doctors) negative attitude/resistance toward formula companies set an example for all staff to comply with BFHI standards regardless of their personal attitudes
Barrier:
There was a general consensus in the governmental hospital that this factor was a major barrier for the initiative as most of the staff had negative attitudes towards implementing this area in particular since they had strong affiliations with formula companies (result of free trips to staff, samples, gifts, personal supply of BMS, etc.…). Whereas in the private hospital, only two participants classified this factor as a barrier since there were only few cases of policy violation among some staff members who promoted BMS due to personal affiliations with formula companies.
Implemented strategy:
Obligatory policy-enforcement forbidding staff members from BMS promotion and imposing disciplinary actions for non-compliance (verbal or written warning, suspension, or dismissal).