Shared learning database

University of Bristol
Published date:
September 2013

Implementing and evaluating Baby Friendly Initiative training for health visiting teams as part of work towards raising breastfeeding rates.

This is in line with NICE CG37 and recommendation 1.3.3 which encourages breastfeeding using the Baby Friendly Initiative as a minimum standard.
Details of practical implementation of community staff training for BFI are available from Nicki Symes, breastfeeding co-ordinator, Bristol City Council :

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

To raise breastfeeding rates across the city of Bristol, to improve health outcomes for mothers and babies and to address health inequalities in relation to breastfeeding.

Reasons for implementing your project

NICE's CG37 recommends the adoption of UNICEF UK Baby Friendly Initiative [BFI] maternity and community standards as a minimum way of improving breastfeeding support for mothers. This is echoed in statement 5 of QS 37. The maternity award has been shown to raise breastfeeding rates. In common with the rest of the UK, breastfeeding initiation rates in Bristol had been steadily rising. Southmead Hospital was one of the first to achieve BFI accreditation in 2004 and St Michael's Hospital achieved their award in 2009. Initiation rates rose at a faster rate in Bristol with each accreditation. Continuation rates at 6-8 weeks however, were static. There was no case study of implementing community standards across a city wide area and so the effects on breastfeeding continuation rates were unknown.

Bristol Primary Care Trust and Bristol City Council further invested in breastfeeding public health work via a Local Area Agreement to support a 3 year, one million pound reward target project to raise breastfeeding rates at initiation and 6-8 weeks and address inequalities. Work on this project began in June 2007 and was completed in March 2010.

Two part-time Breastfeeding Development Managers [BDM] were appointed and an Associate Director of Public Health championed the work, accessing funding and highlighting need for the work. After carrying out a survey of breastfeeding support across the city, it was agreed to work towards the adoption of the UNICEF UK Baby Friendly Initiative Community standards. The BDM's were joined by an experienced BFI manager for 30 days over one year [May 2008-May 2009], to support the BFI work. The work towards BFI accreditation began in November 2008 when the project was registered and the final part of the award was achieved in March 2010. Part of this work involved the training of all health visiting staff and was externally evaluated [Ingram 2010 see 'supporting material'] as outlined below.

How did you implement the project

£50,000 was awarded from a public health grant scheme for health visitor training and £30,000 was allocated to Bristol University for external evaluation. At the request of health visiting managers, £10,000 was provided to offer 'backfill' of staff to employ 'bank' cover for health visiting bases to facilitate staff to be released for training where there were staff shortages. Training sessions were held in Children's Centres, who offered the venues for free, and lunch was provided and welcomed by staff. Crèches were offered due to request from managers for staff with pre-school children, but these were rarely used.

External 3-day training was purchased from BFI and all staff attended over a 6 month period. Courses were slow to fill up initially but then gained momentum as staff recommended the course to their colleagues. A proactive approach was needed to fill courses. An extra couple of 2-day training courses were held for Children Centre staff, family support workers, breastfeeding counsellors and a few health visiting staff who had been unable to attend the 3-day course. Attendees were given a pack of materials to support WHO standards [lanyards, diary covers, age in weeks]. Breastfeeding team staff delivered training materials for the trainers and supported the distribution of research questionnaires.

Key findings

Evaluation methods: 141 health visitors and nursery nurses were trained on mandatory 3-day BFI courses during 2008; 137 staff (100 health visitors, 37 nursery nurses) took part in the evaluation. Breastfeeding attitudes, knowledge and staff confidence in helping mothers to breastfeed were measured using a validated Breastfeeding Questionnaire and a Self-efficacy tool at 3 time points before and after training.

Findings: Breastfeeding rates at 8 weeks increased significantly and a baby born in 2009 was 1.57 times more likely to be breastfed than one born in 2006. Statistically significant improvements in staff breastfeeding attitudes, knowledge and self-efficacy were seen after attending the course; also increases in the appropriate management of breastfeeding problems.

Process evaluation interviews with 43 health visitors, nursery nurses and managers explored views of the training and changes in practice. The response to the course was overwhelmingly positive and felt to be extremely worthwhile. It has led to renewed enthusiasm, improved the consistency of advice amongst team members and raised confidence levels of all staff who help mothers with breastfeeding. Health visitors felt confident about enabling nursery nurses to take a greater role in breastfeeding support. A small survey of mothers reported increases in exclusive breastfeeding and signs of increased breastfeeding self-efficacy.

Making the training mandatory and across the whole PCT has improved the consistency of breastfeeding advice and confidence of all health care staff who help breastfeeding mothers. Bristol was awarded first "Baby Friendly city" status with both maternity hospitals and the community all accredited with BFI awards and was the first city to achieve the community award.

Key learning points

  • This project was carried out at a time of change for the local health visiting service: the merger of two PCTs followed by transfer of the service to an acute trust.
  • The BFI accreditation is a change management process and has its own momentum. It requires work practice and culture to alter. The training was a central part of this change process.
  • The speed of change required by working in the target project meant that there was not capacity in the team to do a major training project. The BDM's commissioning services and offered breastfeeding awareness training to GP's, Children's Centre staff, link workers, family support workers and others associated with care of mothers and babies.
  •  When implementing a mass training programme in a defined timescale the progress needs to be closely monitored and co-ordinated and communicated with staff and managers so that the resource is well used and everyone is trained by the end of the allotted time. A flexible approach as well as a close monitoring is recommended.
  • Breastfeeding rates rose and staff were more confident and knowledgeable about breastfeeding, so the costs incurred seem justified. At the end of the breastfeeding target reward project, income was generated as the continuation target had been surpassed.

For further reading please see:

Primary Health Care Research & Development doi:10.1017/S1463423610000423

Contact details

Dr Jenny Ingram
Senior Research Fellow
University of Bristol

Primary care
Is the example industry-sponsored in any way?