Five themes were identified from the analysis: 1) Human rights of child and mother, 2) Dependency on precarious leadership, 3) Lack of budget prioritization, 4) Fragmented and inconsistent implementation of Ten Steps across the health system, and 5) Negotiating with family, community and culture.
Theme 1: Human rights of child and mother
Participants emphasized their belief that, “Humans should drink mother’s milk not cow’s milk to fulfil human rights…” (Participant 2). This belief underpinned their everyday work in providing support and education to breastfeeding mothers. However, mothers’ rights to choose was also acknowledged “…but it is their decision, depends on their families as well”. Implementing the Ten Steps was participants’ passion, “Since we're still young and idealist. We have passion to support patients.” (Participant 11) with an underlying awareness of the implications of breastfeeding for future health and wellbeing, “we shouldn't be selfish and should be aware of our children’s future” (Participant 13).
Participants also discussed their rights as employees to be supported to breastfeed “We should also take care of the employees by providing facilities such as sofas, sink. So, we take care of patients, and we also get our rights.” (Participant 7). The facility has a lactation room that can also be used by staff, nevertheless “We hope to have it in each floor” (Participant 4).
Theme 2: Dependency on precarious leadership
Participant admitted that “The Ten Steps is implemented in this hospital since several years ago.—no infant formula or bottles, we also have a lactation room… In my division, the program runs well enough,—exclusive breastfeeding, breastfeeding counseling, breastfeeding techniques” (Participant 4). At the same time, they understood how important the leaders were to maintaining commitment to the Ten Steps, “It depends on the leader's vision and mission, whether he is profit-oriented or not. Sometimes people are too profit-oriented, then infant formula products marketing need to be increased to achieve targets. If the initial vision and mission is breastfeeding, and it is in the indicator, then the leader should stick to it. Don't let the baby formula enter the hospital. The procurement of government hospital will not be done if it’s not approved by the leader. If the leader is already supporting breastfeeding, the procurement will follow. But, if they are money-oriented, it would be dangerous.” (Participant 12). Participants described the shared vision for breastfeeding that was currently in place at the hospital, “…all teams in this hospital, the obstetrician and paediatrician also the surgeon have no problem with Early Initial Breastfeeding [EIB].” (Participant 6). They proudly described their rooming-in unit. “We also have a rooming-in unit for phototherapy. So, if the mother has been discharged or if the baby has been discharged and needs to do phototherapy, in the other hospital, the baby is isolated in the phototherapy room and the mother cannot stay. Here, we have a rooming-in unit.” (Participant 11).
They expressed their concern when the leaders had to change. As a government hospital, leadership is assigned for five-year periods. “Maybe since it's a government hospital, I mean, the executives and employees are always changing. So, when the executives are changed, we need to persuade them again to ascertain that it is Mother and Baby-Friendly Hospital. Because I know the offer from infant formula company is huge. So, I need to tell the executives that this hospital shouldn't accept that. And we don't know if there will be any change later. So, the obstacle is to maintain our vision. Employees keep changing, too. There are new staff. These new staff need to understand that this is pro-breastfeeding hospital.” (Participant 11).
Theme 3: Lack of budget prioritization
Despite having support from leaders, participants explained that there was no training specific related to breastfeeding for staff. “…in training sessions, we don't only talk about breastfeeding, but all matters. And it's mainly related to SKP [Sasaran Kerja Pegawai/Employee Performance Target]. The breastfeeding is addressed together with skill competence. It can save the budget.” (Participant 8). Participants compared their situation with hospitals that receive sponsorship from formula companies, and the perceived impact of not receiving this financial support was a lack of staff training, especially regarding breastfeeding. “we don’t have enough budget. The budget for training will be allocated for other important necessities. There are other more important programs.” (Participant 11). Comparing with their previous work experience, “…We usually have many trainings, seminars. But, we don’t even have one.” (Participant 10). This was perceived to be related to hospital leaders’ budgetary prioritization.
While midwives received breastfeeding education during their training degree in midwifery, nurses did not have that education “…it will be better for nurses to get training.” (Participant 12).
Lack of staff resources was described as one of the barriers in implementing Ten Steps. Especially in implementing Step 2, participants explained “In the past, we had fewer patients. We could provide EIB around 1–2 h. Usually, we finished it in 2 h. But nowadays, the patients number increasing, so we can’t do that anymore.” (Participant 8).
Theme 4: Fragmented and inconsistent implementation of ten steps across the health system
Participants expressed their enthusiasm for the BFHI and regretted that there was no longer a specific accreditation. “The accreditation standard for Mother and Baby-Friendly Hospital [MBFH] in Indonesia no longer exists, the last one was in 2007 or 2008. At the moment we don't have such specific accreditation. But the previous Hospital Accreditation Committee [Komite Akreditasi Rumah Sakit (KARS)] 2012 actually adopted the MBFH policies.” (Participant 11).
Participants described their experiences when receiving patients who did not understand about Ten Steps implementation. “If the patient has regular check up here they are aware that this hospital is pro-breastfeeding. But, most of our patients have never checked up here.” (Participant 11). As part of the hospital’s standard procedures, patients were given a general information sheet and were required to provide consent prior to admission “Because each patient should have been given general consent prior to admission and there are points regarding EIB and exclusive breastfeeding… But for emergency [caesarean] section patient—have they also been told during admission?..” That the patient should do EIB, how we do it. Or that this is Baby-Friendly Hospital, so the baby should be breastfed. (Participant 8).
After discharge, mothers returned to the community health center to continue postnatal care. Participants were disappointed that they could not follow-up with mothers again. “BPJS [Badan Penyelenggara Jaminan Sosial/Social Insurance Administration Organization] patients can’t do a check up here. That is the problem.” (Participant 11).
Theme 5: Negotiating with family, community and culture
Participants described challenges to enabling breastfeeding with family. “In the birthing room, we provide early initiation of breastfeeding [EIB] to newborn baby. In the birthing room, the baby will stay for 2 h, including EIB for 1 h, and if the mother has recovered, we teach her how to breastfeed. This hospital supports them to learn how to breastfeed, but it is their decision, depends on their families as well. Often, the families are impatient. Such as, when the baby won't stop crying, they prefer to give the baby infant formula. At the end, it all comes back to their culture.” (Participant 13).
Most participants agreed that family had strong influence, especially grandmothers. “The complaints usually came from the grandmothers, "The baby is crying, don’t you care at all?" (Participant 11). Participants believed that widespread formula marketing in the community had a great influence on family decisions, “Some of them prefer formula.” (Participant 10).
Mothers and families were also perceived to bring beliefs and traditions which sometimes were not beneficial in breastfeeding process, “The colostrum was thrown away. We need to give them education. It’s because of the culture.” (Participant 2) Participants agreed that this increased their workload as they needed to counsel and educate not only the mothers, but also grandmothers. “We have difficulties to educate the family, especially the grandmothers.” (Participant 9).
Participants admitted that “if our patient is given infant formula by their family, we immediately tell them strongly, our voice intonation increase. And, if the patient is offered bottle filled with formula we'll immediately hold a counseling, how should I say it? Actually, it is not a problem, but it is better to tell them nicely. It is like we are accusing them. Although the intention is good” (Participant 4). Participants felt that at times they were forcing the mothers to breastfeed, whereas it would be much more effective to educate them, so their decisions were informed and unforced, “…when we told patients it seemed we've forced them like, "you should breastfeed the baby". Maybe we can educate them. (Participant 8).