An examination of factors that challenge and facilitate implementation of the Baby Friendly Hospital Initiative in Australia and Ten Steps to Successful Breastfeeding in Indonesia: a convergent parallel mixed-methods study of two hospitals

Background Breastfeeding, which brings benefits to both mother and infant health, the environment and the economy, is a human rights issue. However, only 48% of babies are breastfed within one hour of birth and only 41% of babies are exclusively breastfed globally. The first few days after birth is a critical period for establishing breastfeeding. WHO and UNICEF launched the Ten Steps to Successful Breastfeeding (Ten Steps) in 1989 (revised in 2018) to ensure that mothers receive adequate breastfeeding education and support. In 1991, the Baby Friendly Hospital Initiative (BFHI) was launched to encourage maternity facilities to implement the Ten Steps; however, in 2016 only 10% of babies were born in BFHI-accredited hospitals globally. Australia and Indonesia face similar issues regarding implementing the BFHI and the Ten Steps. Only 26% of Australian hospitals were BFHI-accredited in 2020, and only 8% of Indonesian government hospitals were considered to be implementing the Ten Steps in 2011. Methods Convergent parallel mixed methods were used to examine facilitators and challenges to BFHI and the Ten Steps implementation in Australia and Indonesia. The quantitative component evaluated the Social Return on Investment (SROI) of implementing these policies. The qualitative component utilised focus groups discussions with midwives and nurses in each context, regarding their experiences and perceptions of implementing the BFHI or the Ten Steps. The two components were integrated using the Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework. Findings The results of the quantitative component found that every US$ 1 invested in maintaining BFHI accreditation in an Australian hospital and implementing the Ten Steps in an Indonesian hospital brought an equivalent of US$ 37 and US$ 49 social return to the community, respectively. The qualitative findings from the Australian hospital emphasized how midwives' belief in breastfeeding was critical in enabling them to negotiate challenges to implementation. While the Indonesian case study highlighted their awareness and understanding of the human rights of children and mothers to manage challenges in implementing the Ten Steps. The importance of continuity of care and adequate time with midwives throughout pregnancy, birth and the postpartum period were described as critical for implementation of the BFHI and Ten Steps in both settings The two components converged through the social value studies results that indicate a misalignment of social returns with individual organization and clinical level returns. Furthermore, the qualitative studies highlighted that the costs of implementing the BFHI and Ten Steps are only partially being born by the hospital, rather than by the individual midwives and nurses doing the ongoing work of the implementation. This also occurs in peer-support groups and community health services who are critical for implementation but receive no return on their investment. The NASSS integrative analysis highlighted the complexity of implementing policy into health services and clinical practice. Conclusion The complexity of the implementation of the BFHI and the Ten Steps requires national multi-sectoral collaboration. This study provides the first evidence of the social return on investment of implementing the BFHI and Ten Steps in public maternity facilities, providing important incentive for global reinforcement of these initiatives. The NASSS framework focuses on challenges and facilitators of the BFHI and Ten Steps through multiple lenses. Most of these have the potential to be unpredictable. Despite WHO having updated the Ten Steps and BFHI in 2018, it is recommended that barriers, such as the lack of continuity of care and fragmented Ten Steps implementation across health systems must be addressed as a matter of urgency