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Table 4 Content analysis from ‘free text’ response in survey

From: Perspectives about the baby friendly hospital/health initiative in Australia: an online survey

StatementKey concept from participant responseExample verbatim text
Policy and guideline support and improvement of breastfeeding and the BFHI1. Lack of national support of the WHO Code1.1. ‘National support is lacking strength for this especially in relation to MAIF [Manufacturers and Importers Agreement 1992].’ (Participant 48)
1.2 ‘I believe that we should embrace all recommendations from the WHO when it comes to BFI/BFHI including stopping the promotion and advertising of any formula (newborn or toddler milks).’ (Participant 263)
2. A need for policy support for the BFHI2.1 ‘I believe that at a policy level BFHI needs to be a mandatory accreditation.’ (Participant 314)
3. A need for policy and/or guideline improvement.3.1 ‘The increased documentation of compliance is time consuming, resented by staff, and makes mothers feel like they are being excessively scrutinised … the BFHI compliance regulations are becoming counterproductive to breastfeeding promotion.’ (Participant 85)
Leadership support to implement the BFHI1. A need for government support1.1 ‘The uptake of BFHI requires high level governance and funding at a government level in every aspect of health to effect any change.’ (Participant 106)
2. A need for support by senior executive health staff2.1′Senior executive health staff do not prioritise implementation of BFHI sufficiently in my area.’ (Participant 38)
3. Supporting mothers3.1 ‘Peer support and referral to organisations such as the Australian Breastfeeding Association should be encouraged and nurtured.’ (Participant 43)
Breastfeeding and BFHI related knowledge1. Lack of essential knowledge and skills amongst staff1.1 ‘Our health professionals’ breastfeeding advice is inconsistent and out-dated at best.’ (Participant 26)
2. A need for updated training and required qualifications2.1 ‘I recall when the initiative was first implemented in our health service. All staff were trained. Since then I have not seen any updates or requirement to re-accredit, which would lead to new staff not being aware of the policy.’ (Participant 87)
3. A need for easy access to education3.1 ‘Easy access to staff education and staff support is a key component to BFHI.’ (Participant 47)
4. Providing education for mothers and families4.1 ‘More recognition of long-term health benefits of breastfeeding to society by government. .. and education services with resources to enable education and support for individuals and families to be empowered to feed their babies.’ (Participant 121)
5. A need for knowledge improvement about breastfeeding in the community5.1 ‘There also needs to be more community awareness around breastfeeding.’ (Participant 135)
Accreditation and reaccreditation1. More BFHI accredited facilities are required1.1 & 2.1 ‘More hospitals should be BFHI accredited and those who already are should be more closely monitored.’ (Participant 1)
2. A need for monitoringAs Above
3. Cost of accreditation3–1 ‘It’s very expensive for hospitals to achieve accreditation.’ (Participant 56)
4. BFHI was not considered essential and/or beneficial4.1 ‘I do find BFHI accreditation restrictive to midwifery practice and can serve to alienate some mothers by not supporting their informed decision making.’ (Participant 92)
Implementation complexity1. Staff attitudes towards breastfeeding and the BFHI1.1 ‘I think the management of the hospitals and maternity units need to see breastfeeding as valuable to go for BFHI accreditation.’ (Participant 324)
2. Community attitudes and support towards breastfeeding2.1 ‘I was still subjected to public criticism when breastfeeding my infants in public. .. so I don’t think as a society breastfeeding is as well accepted as it should be.’ (Participant 88)
3. Media support of breastfeeding3.3 ‘Media needs to support breastfeeding and portray it as the normal.’ (Participant 136)
Communication among stakeholders1. Importance of a multidisciplinary approach to the BFHI1.1 ‘BFHI needs to be multidisciplinary and led by national government. .. (Participant 60)
2. Importance of a continuous relationship between mothers and healthcare staff2.1 ‘Maternal child health nurses have an ongoing relationship with the mother and baby and are more likely to influence continued breastfeeding than [the] BFHI.’ (Participant 163)
3. Importance of communication skills and/or interaction between healthcare staff and mothers3.1 ‘I am often disappointed by what can be seen as bullying type practices from midwives, and almost inflexible militant type approach to upholding BFHI practices. This often is a bone of contention and actually put women off breastfeeding as they feel they can’t live up to the expectations of the inflexible breastfeeding advocate.’ (Participant 105)
A need for improvement in carea1. A need for improving care provided for mothers’ post discharge1.1 ‘To me this means BFHI is working, but more programs are needed to support women after they go home from hospital.’ (Participant 166)
1.2 ‘Postnatal care is the least well-regarded part of birthing continuum and least well resourced.’ (Participant 108)
1.3 ‘BFHI is great but so many mothers are discharged on day two, and support services following are not adequate.’ (Participant 319)
1.4 ‘Community BFHI needs more emphasis.’ (Participant 96)
1.5 ‘Also more continuity of care models would improve breastfeeding rates.’ (Participant 141)
2. A need for improved care provided by hospitals2.1 ‘Hospitals should refer more readily to the community-based family care.’ (Participant 27)
2.2 ‘More hospitals should have breast milk storage banks. To provide babies in NICU and SCN donor breast milk as an alternative to formula.’ (Participant 141)
2.3 ‘Women need far more support to initiate breast feeding in a hospital birth context.’ (Participant 173)
2.4 ‘Early discharge from hospital lessens breastfeeding support. .. More IBCLCs are required in hospitals and CFHN clinics for early breastfeeding support.’ (Participant 334)
  1. aThis statement was constructed in response to the ‘free text’ question at the end of the survey