A rationale for conducting the re-assessments was to determine whether the training and institutional re-orientation needed to remain designated as Baby-Friendly was being sustained and that it translated into improved practices. We expected that the findings from the assessment in the Accra Metropolis would serve as a gauge for BFHI performance elsewhere in Ghana, where the facilities are less endowed with often less skilled capacity. Our finding that none of the six designated facilities in the Accra Metropolis was adherent to the Ten Steps to successful breastfeeding was surprising. It suggested that the adherence to the Ten Steps in designated facilities outside Accra may be even poorer than observed in Accra. In addition to these six facilities which have performed poorly on the Ten Steps, all the other designated maternity facilities which have not been re-assessed continue to be advertised as Baby-Friendly with potential adverse implications for infant breastfeeding promotion; elsewhere, the designation will have been lost until they meet the BFHI standards [15, 16].
None of the facilities was compliant with Steps One and Two. This was despite the fact that a written policy on the BFHI existed in all the facilities. The deficiency, however was that the existing policies did not communicate all the Ten Steps to successful breastfeeding, except in one facility. Also, in four of the facilities, although the policy was available, it was not displayed at relevant places for the benefit of staff and clients. Concerning Step Two, lack of funds was given by the hospital management as the reason for failing to utilize the existing training guide to build the capacity of the clinical staff on the Code and the Ten Steps. This excuse may be because in Ghana, it is not uncommon for staff working in public institutions to receive training outside the workplace setting and also to earn extra income (often paid by external organizations providing the training) for participating in a training program. Thus staff are less motivated to participate in training that is not linked with extra income.
There was also low adherence with Steps Three, Four, Five and Eight. This is not surprising since the clinical staff were not adequately prepared through training to support mothers to practice appropriate feeding in the immediate postpartum period. Poor knowledge and skills of clinical staff to support women in breastfeeding is not a surprising finding as reported by Okolo and Ogbonna in Nigeria [17]. Also, the finding that Step Seven was adhered to by all facilities is aided by space constraints in most hospitals, thus facilitating the keeping of infants with their mothers.
A similar pattern was observed for adherence to the Code on marketing of breast milk substitutes. Our findings show that there was low adherence with the Code in the six maternity facilities. Even more disturbing is the finding that the health staff had poor knowledge on the reasons for not permitting distribution of free formula samples. Two key implications are drawn from this finding of poor adherence to the BFHI standards. Firstly, many mothers who deliver their babies at designated Baby-Friendly facilities may be missing the opportunity to receive adequate support to breastfeed appropriately. Secondly, the low adherence may partly explain the low rates of timely breastfeeding initiation in Ghana [18, 19].
The literature on BFHI has only a few published reports on facility re-assessments. In Brazil, Maura de Araujo and Schmitz [20] have reported that out of 172 designated hospitals reassessed, 82% were fully compliant to all the steps. In their study, the steps that had the lowest compliance were steps two and three, bearing similarity to our findings. Earlier in 1999, Dodgson et al., had reported low compliance with the Ten Steps in 95 Minnesota Hospitals in the early stages of implementing BFHI [21]. In the African context, however, no published reports on BFHI re-assessments were identified in our search of the literature. Perhaps, this is the first reported study on re-assessment of BFHI in the sub-Saharan Africa region.
The facility staff attributed the high rate of non-adherence to both the Ten Steps and the Code to multiple reasons including high trained staff attrition, inadequate in-service training for new staff, high client-staff ratios, and inadequate support for regional and national program monitoring. Beyond these barriers, there is also lack of strong leadership and sustained program planning to allow integration of BFHI into existing health system structures. As a result, only a few trained national assessors have the mandate to go round the entire nation to perform supportive monitoring as well as assessments and training for designation. Since the assessors carry out these activities in addition to their primary duties, both facility designation and monitoring is often left unattended to. In the future, the Ghana Health services and the Ministry of health should consider decentralizing the assessment procedure in order to remove bottlenecks in mobilizing assessors across the country.
It is important to recognize that re-assessment of designated Baby-Friendly facilities is recommended at least every three years [9]. In Ghana, however, re-assessment has not been implemented routinely. Rather, there is periodic supportive monitoring that is carried out by a National team of trained assessors. The frequency of supportive monitoring is, however, infrequent due to inadequate funding of the BFHI program. As a result, only a few of the designated facilities benefit from monitoring visits by the assessors each year.
The findings of this study should be interpreted also within the context that the re-assessment tools utilized were the revised versions of the tools that were used to designate the facilities. There are key differences that have been identified between the original assessment tools and the revised version. It is possible, therefore, that if the original tools had been used, different levels of compliance may have been observed. Nevertheless, the findings based on the revised tools reflect current expectations of the BFHI program and should serve as basis for interpreting future re-assessments.
