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ii Conduct of Post-Training Evaluation on Lactation Management – A Guide

This Guide was made possible by the generous support of the American People through the United States Agency for International Development (USAID). The contents of this Guide are the sole responsibility of RTI International and do not necessarily reflect the views of USAID or the United States Government.

iii Conduct of Post-Training Evaluation on Lactation Management – A Guide

iv Conduct of Post-Training Evaluation on Lactation Management – A Guide

v Conduct of Post-Training Evaluation on Lactation Management – A Guide

Table of Contents Foreword ........................................................................................................................................ vii

Acknowledgments ............................................................................................................................ ix

List of Acronyms .............................................................................................................................. x

About this Guide ............................................................................................................................ xiii

I. Background .................................................................................................................................. 1

II. Objectives of the PTE for LMT ..................................................................................................... 2

III. The PTE for LMT Process ........................................................................................................... 2

1. Preparatory Activities ............................................................................................................... 3

2. Actual Conduct of the LMT PTE Visits ...................................................................................... 7

3. Feedback to the P/CHO/DOHRO ............................................................................................. 8

IV. Orienting the LMT PTE Team on the PTE Set of Checklists ....................................................... 9

References .................................................................................................................................... 12

Annexes ........................................................................................................................................ 13

Annex A: Post-training Monitoring and Evaluation (PTE) Checklist Kit for Lactation Management

Training (LMT) ............................................................................................................................... 15

Annex B: Summary Table of LMT PTE Results ............................................................................. 29

Annex C: The Ten Steps to Successful Breastfeeding - A Joint WHO/UNICEF Statement ............ 31

Annex D: Breastfeed Observation Aid ............................................................................................ 33

Annex E: (Milk Code EO No. 51 on “Adopting a National Code of Marketing Breastmilk Substitutes,

Breastmilk Supplements and Related Products, Penalizing Violations Thereof and for Other

Purposes.”) .................................................................................................................................... 35

Annex F: (DOH AO 2007-0026 on the “Revitalization of the Mother-Baby Friendly Hospital Initiative

in Health Facilities with Maternity and Newborn Care Services”) ................................................... 61

Annex G: (RA 10028 on “An Act Expanding the Promotion of Breastfeeding, Amending for the

Purpose R.A. No. 7600, Otherwise Known as ‘An Act Providing Incentives to All Government and

Private Health Institutions with Rooming-in and Breastfeeding Practices and for Other Purposes’.”)

...................................................................................................................................................... 77

Annex H: Joint DOH-DOJ-DTI-DSWD AO 2012-0027 on the “Inter-Agency Committee Guidelines in

the Exercise of their Powers and Functions as Stated in E.O. No. 51, series of 1986, otherwise

known as “The National Code of Marketing of Breastmilk Substitute, Breastmilk Supplements and

Other Related Products, and its Revised Implementing Rules and Regulations. ............................ 87

vi Conduct of Post-Training Evaluation on Lactation Management – A Guide

vii Conduct of Post-Training Evaluation on Lactation Management – A Guide

Foreword

A vital element of the Department of Health’s (DOH) thrust to revitalize its Mother/Baby-Friendly Hospital Initiative is to strengthen the capability of health service providers (HSPs), particularly nurses and midwives from hospitals and public and private lying-in clinics with maternity and newborn care services, in lactation management. After undergoing the three-day Lactation Management Training (LMT) Course, the trained HSPs are expected to be able to provide quality care by counseling pregnant and postpartum mothers on exclusive breastfeeding (EBF) and assisting them in initiating breastfeeding right after delivery. For this to happen, it is important that HSPs trained in lactation management be followed up after two to three months for post-training evaluation (PTE) to ensure that they are able to apply in their respective work environments the knowledge and skills they acquired during training. With technical assistance from the USAID-LuzonHealth Project, a set of PTE Checklists for LMT has been developed and pretested in Albay Province, following the conduct of two batches of Training of Trainers’ Course in Lactation Management for Region V. The trained trainers were followed up for PTE using this set of checklists, before they were certified by the DOH Regional Office V as LMT trainers. This set of PTE Checklists for LMT has been packaged as part of this manual. I am very happy to note that in Region V, we have a quality system in place in terms of ensuring that LMT-trained HSPs are followed up through PTE to check if they are indeed providing quality care to their pregnant and post-partum patients. It is expected that with more HSPs trained in lactation management and followed up through PTE, more women will be reached with individual or small group-level education on the benefits of EBF and given the needed support to initiate EBF, which in turn are expected to increase EBF practice. I hope that other regions in the country will find this manual useful in doing post-training follow-up of their HSPs.

NAPOLEON L. AREVALO, MD, MPH OIC Regional Director DOH Regional Office V

viii Conduct of Post-Training Evaluation on Lactation Management – A Guide

ix Conduct of Post-Training Evaluation on Lactation Management – A Guide

Acknowledgments

Sincere gratitude is extended to the following individuals for their invaluable contribution in the development and review of this LMT PTE Guide and all tools contained therein:

1. Dr. Ma. Theresa Belarma, Medical Specialist II, Albay Provincial Health Office

2. Ms. Vicenta Borja, RN, MPH, former DOH National Infant and Young Child Feeding Program Manager

3. Ms. Sheree Longaza, Provincial Nutrition Coordinator, Albay Provincial Health Office

4. Ms. Alma Lozada, Regional Nutrition Coordinator, Department of Health Regional Office V

5. Ms. Salve Lucillo, Nurse Assistant, Josefina Belmonte Duran Memorial District Hospital

6. Ms. Cauline Ruth Pangan, Associate Professor I, Bicol University

7. Ms. Jane Pecson, Training Coordinator, Bicol University

8. Ms. Esther Valladolid, Associate Professor V, Bicol University

x Conduct of Post-Training Evaluation on Lactation Management – A Guide

xi Conduct of Post-Training Evaluation on Lactation Management – A Guide

List of Acronyms

ANC Antenatal Care AO Administrative Order BFHI Baby-Friendly Hospital Initiative CEmONC Comprehensive Emergency Obstetric and Newborn Care COC Certificate of Commitment CS Caesarian Section DMO Development Management Officer DR Delivery Room DOH Department of Health DOHRO DOH Regional Office EBF Exclusive Breastfeeding EINC Essential Intra-partum Newborn Care EO Executive Order HSP Health Service Provider IEC Information, Education and Communication IRR Implementing Rules and Regulations LMT Lactation Management Training LR Labor Room LuzonHealth Integrated Maternal, Neonatal, Child Health and Nutrition/Family Planning (I-MNCHN/FP) Regional Project in Luzon MBFHI Mother/Baby-Friendly Hospital Initiative MCH/FP Maternal and Child Health/Family Planning MHO Municipal Health Officer MNCHN Maternal, Neonatal, Child Health and Nutrition NGO Nongovernment Organization NICU Neonatal Intensive Care Unit OPD Outpatient Department P/CHO Provincial/City Health Office PDO Provincial DOH Office PHN Public Health Nurse PMG Project Management Group PTE Post-training Evaluation RA Republic Act RHU Rural Health Unit TOT Training of Trainers USAID United States Agency for International Development WHO World Health Organization

xii Conduct of Post-Training Evaluation on Lactation Management – A Guide

xiii Conduct of Post-Training Evaluation on Lactation Management – A Guide

About this Guide The need to conduct post-training evaluation (PTE) for the different Department of Health (DOH) training courses is embodied in DOH Administrative Order No. 147 s. 2002 (Revised Guidelines Governing Health Human Resource Training and Development Programs) and in DOH Memorandum No. 2012-0166 (Reiterating the Implementation of Level 1 to 4 Training Evaluation for Training Programs). In the case of the Lactation Management Training (LMT) Course, however, the WHO/UNICEF 2009 training manual (Breastfeeding Promotion and Support in a Baby-Friendly Hospital) being used for the training, does not include any PTE guide or checklist. In response, the DOH Regional Office (DOHRO) for the Bicol Region initiated the development of a set of PTE checklists on lactation management with technical assistance from USAID’s LuzonHealth Project. The checklists were pre-tested among trained trainers who participated in the Training of Trainers’ Course in Lactation Management conducted by DOHRO V for the Bicol provinces. The experiences of the trained trainers in the use of the checklists were documented and taken into account in developing this LMT PTE Guide for possible nationwide adoption by the DOH Central Office. This Guide describes the process and tools used in conducting a PTE among HSPs who have undergone the three-day LMT Course, two to three months after the training, to ensure that they are able to apply in their respective work environments the knowledge and skills they have acquired. The PTE also aims to assess if the health facilities (hospitals and RHU birthing clinics and private birthing clinics) where these trained HSPs work are supportive of the provision of quality breastfeeding management services and are implementing the Ten Steps to Successful Breastfeeding. Ideally, the LMT trainers who trained the HSPs should be the ones to do the PTE. If the PTE is being conducted by trainers who have only been recently trained in lactation management, they should be observed by their trainers in the Training of Trainers’ Course in Lactation Management, who would then recommend them to the DOHRO for certification of competency as LMT trainers. The LMT PTE kit contains the following checklists: Part I. Health Facility Profile Part II. Assessing the Implementation of the Ten Steps to Successful Breastfeeding 1. Interview Questionnaires 1.1 For Health Facility Managers 1.2 For Health Service Providers Trained in LMT 1.3 For Patients (Pregnant Women, Postpartum Women) 2. Service Provision Observation Checklist 2.1 Outpatient Department (OPD) for Antenatal Care (ANC) 2.2 Labor Room (LR) and Delivery Room (DR) Areas; Neonatal Intensive Care Unit (NICU) 2.3 Obstetrical Ward 3. Facility Observation Checklist

xiv Conduct of Post-Training Evaluation on Lactation Management – A Guide

3.1 Outpatient Department (OPD) for Antenatal Care (ANC) 3.2 Labor Room (LR) and Delivery Room (DR) Areas; Neonatal Intensive Care Unit (NICU) 3.3 Obstetrical Ward 4. Records Review Part III. Summary of Findings and Recommendations It is expected that the regular conduct of the LMT PTE for all HSPs trained in LMT, followed up with regular program monitoring and supportive supervision, will help ensure that the trained HSPs will get the needed coaching and mentoring from their trainers and later from their supervisors to continually provide quality breastfeeding services in line with the “Mother-Baby Friendly Hospital Initiative” in their health facilities.

1 Conduct of Post-Training Evaluation on Lactation Management – A Guide

I. Background

The challenge in child survival is ensuring that a child be given the best start in life through breastfeeding – for optimum nutrition, growth, health and development. The mother should be kept healthy and happy as well to be able to provide her baby the needed care. These, in line with the Philippine Health Agenda of “All for Health towards Health for All,” will ultimately lead to the achievement of the Sustainable Development Goals of reducing child and maternal deaths, ending all forms of malnutrition, and achieving universal and equitable access to safe and affordable drinking water and adequate sanitation and hygiene. The first 1000 days of the child’s life are crucial, and this is the very reason why the highest level of care during pregnancy, labor, delivery, and postpartum has to be provided by trained health staff to support women in caring for their children, especially during the early days of the newborn. Guided by DOH A.O. No. 2007-0026 entitled “Revitalization of Mother-baby Friendly Hospital Initiative and Health Facilities with Maternity and Newborn Care Services”, the DOH Central Office and the DOHROs lead the strengthening of the MBFHI by providing training in lactation management to health service providers (HSPs) from hospitals and lying-in clinics with maternity and newborn care services.

The MBFHI includes a global assessment and certification scheme that: (1) recognizes the achievement of health facilities with practices that support breastfeeding; and (2) encourages health facilities that are not so supportive to improve on practices that support breastfeeding. An MBFHI certification or at least a letter of commitment to become a Mother/Baby-Friendly hospital/facility is issued by the DOH for health facilities that are able to comply with the implementation of the “Ten Steps to Successful Breastfeeding” (See Annex A). The Lactation Management Training (LMT) is a three-day (20 hours) training course primarily intended for HSPs from hospitals, rural health units (RHUs) with birthing clinics, and private birthing clinics. These HSPs include doctors, nurses and midwives who have direct contact with pregnant women and mothers with newborn infants. The training provides a common foundation for basic breastfeeding management by increasing the capability of health service providers in counseling pregnant and postpartum mothers on exclusive breastfeeding (EBF) and assisting them in initiating breastfeeding right after delivery. It is expected that with more health service providers trained in lactation management, more women will be provided with individual or small group-level education on the benefits of EBF, which in turn is expected to increase EBF practice. Trained HSPs must also be able to successfully advocate for the support of hospital administrators, policymakers, and government officials, so that appropriate policies that support optimal infant feeding will be put in place, thus ensuring the sustained implementation and practice of EBF. Health service providers who underwent the LMT course therefore need to be followed up by their trainers after training to ensure that the requirements of MBFHI implementation are achieved. It is essential that the trained staff be monitored and evaluated at two to three months after training to determine if they are able to apply the knowledge and skills learned during training. Areas needing improvement can thus be identified and appropriate mentoring provided. These post-training activities are important to strengthen the trained HSPs’ capacity and confidence in providing quality health services related to EBF counseling and in initiating breastfeeding among postpartum mothers. This way, they are also enabled to make and sustain their hospital/maternity


lying-in clinics as Mother/Baby-Friendly health facilities. A set of Post-Training Evaluation (PTE) Checklists for LMT will be used to standardize the process and content of the activity.

Selected technical staff of the DOHRO, Provincial DOH Office (PDOHO) and Provincial/City Health Offices (P/CHO) should also be included in the three-day LMT course to ensure program oversight, including post-training follow-up and support. After undergoing the LMT, the DOHRO/PDOHO and P/CHO technical staff can later undergo the Training of Trainers’ (TOT) Course in Lactation Management. They will then become part of the pool of trainers to sustain the conduct of future LMT courses and PTE for newly hired health service providers.

II. Objectives of the PTE for LMT The objectives of the Post-Training Evaluation for the Lactation Management Training are the following:

1. To determine if the trained HSPs are able to competently provide basic breastfeeding management services as learned during the 20-hour LMT course.

2. To determine if their facilities are supportive of the provision of quality breastfeeding management services and are implementing the “Ten Steps in Successful Breastfeeding” as they were trained in.

3. To assist the HSPs in identifying problems they may have in applying the knowledge and skills learned, and in finding solutions to these problems.

4. To assist them in reviewing and adjusting their action plans to improve MBFHI practices. 5. To determine if the training has resulted in client satisfaction with the services provided in

the HSPs’ facility.

III. The PTE for LMT Process The PTE will be conducted by the LMT course trainers from the DOHRO, P/CHO and partner nongovernment organizations (NGOs) for trained HSPs from hospitals and maternity lying-in clinics. If the Regional and Provincial/City Maternal and Child Health/Family Planning (MCH/FP)/Nutrition Coordinators and Health Education and Promotion Officers (HEPOs) were not part of the training team that conducted the LMT for the batch of service providers to be followed up, they should be invited to join the PTE team. The PTE activity should be conducted two to three months after the training. The PTE for LMT process consists of three phases, as follows:

1. Conduct of preparatory activities – The LMT PTE Team meets to plan for the evaluation activity to ensure its smooth and successful conduct.

2. Actual conduct of the PTE visits – The visits to the identified health facilities are carried out as planned. The PTE Team should be ready to make adjustments in the itinerary in case of sudden changes in the schedule of health facility managers and staff.

3. Feedback to the P/CHO – The PTE Team informs the P/CHO managers on the results of the PTE, particularly on the HSPs’ level of knowledge and skills in EBF counseling and initiating breastfeeding among postpartum mothers. It will also be ideal if the team can provide feedback to the DOHRO, to serve as input to future planning and decision-making for the Regional EBF Strengthening Program.


1. Preparatory Activities

1.1. Preparatory meeting.

With permission from the P/CHO, the LMT Lead Trainer will call a preparatory meeting of the LMT PTE Team ideally about two weeks before the planned date of the activity. The following items should be included in the meeting agenda:

a. Orientation of the PTE Team on the use of the set of PTE checklists by the Lead LMT

Trainer. The different methodologies of generating information for the PTE and the corresponding checklists that should be used for each methodology should be discussed to familiarize everyone on the PTE process and the different forms. The different methodologies include: interviews with facility managers, supervisors, trained HSPs and their immediate supervisors, and clients; observation of service provision; facility ocular observation; and records review.

Later as the need arises, the PTE Team may need to provide coaching, which includes mentoring and provision of feedback, to the trained HSPs. They should therefore be well-versed in the use of the checklists. (A copy of the PTE for LMT Checklists can be found in Annex B. These are also described in more detail in the next section on Conducting the PTE for LMT.) It would be helpful if the PTE Team will practice on the use of the different checklists among themselves during the orientation.

b. Listing of names of HSPs trained in LMT who will be visited for PTE and the names of the

health facilities where they come from. If the PTE Team will not be able to visit all the health service providers that they have trained during the planned PTE period, then they should discuss who should be prioritized for the PTE.

c. Identification of roles and responsibilities/tasking among the members of the PTE Team. The

composition of the PTE Team should be determined and the roles and responsibilities of each member described to ensure a smooth conduct of the PTE visits. The Sample Table below describes the suggested composition of the LMT PTE Team and the roles and responsibilities of each member.

LMT PTE TEAM COMPOSITION ROLES/RESPONSIBILITIES

LMT course trainers who will act as members of the PTE Team (List here the names and designations of the LMT course trainers and the agency/institution they represent, e.g., DOHRO, P/CHO, development partner/partner training institution) 1. 2. 3. 4. 5. 6.

• Provide oversight/direction during the conduct of the LMT PTE.

• Conduct the LMT PTE through: interviews with the trained HSPs, their immediate supervisors, facility managers and clients; observation of service provision; ocular inspection of the facility; and review of records.

• Provide coaching to the trained HSPs as necessary.

• Identify good practices, as well as issues and gaps in service provision related to breastfeeding, and recommend solutions/actions to resolve these.

• Provide feedback on PTE results to the health facility managers, the service providers, the P/CHO and DOHRO managers, and program coordinators.

DOHRO/PDO and P/CHO Program Coordinators

• Be oriented on the use of the PTE for LMT Checklists.

• Observe the PTE process.


LMT PTE TEAM COMPOSITION ROLES/RESPONSIBILITIES

(List here the names and designations of the program coordinators from the DOHRO/PDO and P/CHO who are not LMT trainers yet but who need to be oriented on the PTE for LMT tools and processes)

• Provide feedback on the PTE process and results to their respective office managers for future directions on this activity.

Trained health service providers for PTE (one batch of 24 participants) (List, per health facility, the names of health service providers trained in LMT who will undergo the PTE, including their designation.) Health Facility 1

Health Facility 2

Health Facility 3

Health Facility 4 Health Facility 5

Health Facility 6

Health Facility 7

Health Facility 8

d. Preparation of the PTE schedule indicating the date and time of visits to each health facility

and the names of the PTE members assigned to visit the sites. The duration of the PTE will depend on the number of health facilities to be visited, the number of trained service providers in each facility to be followed up, and the number of LMT trainers available to join the PTE Team. On the average a half day is allotted per health facility. The PTE Team may break up into two sub-teams, depending on the availability of transport vehicles, to fast-track the conduct of the activity.

An example of such grouping into two LMT PTE Sub-teams, based on the illustrative composition of the LMT PTE Team presented above, is given below:

PTE Sub-team A Members: (recommend at least three members) ➢ At least one should be a certified LMT Trainer who will lead the conduct of the PTE

(Regional MCH/FP Coordinator/PDOHO technical staff, Provincial/City Nutrition Officer, Provincial/City HEPO, Partner Health Development Agency Representative)

PTE Sub-team B Members: (recommend at least three members) ➢ At least one should be a certified LMT Trainer who will lead the conduct of the PTE

(Regional Nutrition Coordinator/PDOHO technical staff, Provincial/City FP Coordinator, Provincial/City MCH Coordinator, Partner Health Development Agency Representative)

A Sample Table of the Schedule of Activities for the LMT PTE Activity of the PTE Team is provided below:


Date and Time

Health Facility to Be Visited, Address

Activity HSPs to Be Interviewed

Persons Responsible

Two weeks before the conduct of the LMT PTE (half-day)

P/CHO ➢ Courtesy call on the P/CHO ➢ Preparatory planning meeting, including

coordination with health facilities to be visited ➢ Orientation of the PTE Team on the LMT PTE

process and tools ➢ Practice on the use of the PTE Checklists

among the PTE members

LMT PTE Team Leader

Day 1 AM Health Facility 1

➢ Courtesy call on the head of the facility, briefly orienting him/her and the concerned supervisors and trained HSPs on the objectives and activities to be done during the visit.

➢ Conduct of PTE activities using prescribed PTE Checklists. It is recommended that if the PTE is being conducted for the first time, the PTE Team Leader should first demonstrate how to use the PTE Checklists before the PTE Team breaks up for their assigned tasks. These tasks are:

• Records review

• Interviews with facility managers, trained HSPs and their immediate supervisors, and clients

• Service provision observation to assess competency in performing learned skills

• Facility ocular inspection ➢ Coaching, including mentoring and provision

of feedback) ➢ As a team, brief summary of the PTE findings

using the Part III-A of the LMT PTE Checklist Kit (Annex B)

➢ Provision of feedback to facility managers and supervisors to obtain support for agreed steps with HSPs, and get additional recommendations from them for improving the performance of the trained HSPs.

➢ Brief action planning by identifying issues and gaps in service provision and jointly formulating recommended actions with facility managers and HSPs to resolve identified problems, using the MBFHI Implementation Improvement Plan matrix. (See LMT PTE Checklist Kit Part III-C in Annex B)

HSPs 1, 2 and 3

PTE Sub-team A

Health Facility 2

➢ Same activities as above HSPs 4, 5 and 6

PTE Sub-team B

Day 1 PM Health Facility 3

➢ Same activities as above

HSPs 7, 8 and 9

PTE Sub-team A

Health Facility 4

➢ Same activities as above ➢ PTE Team Meeting - Discussion of

experiences and insights/learnings from the day’s activities

HSPs 10, 11 and 12

PTE Sub-team B

Day 2 AM Health ➢ Same activities as above HSPs 13, 14 PTE Sub-team


Date and Time

Health Facility to Be Visited, Address

Activity HSPs to Be Interviewed

Persons Responsible

Facility 5 and 15 A

Health Facility 6


PTE Sub-team B

Day 2 PM Health Facility 7


PTE Sub-team A

Health Facility 8

➢ Same activities as above ➢ PTE Team Meeting - Discussion of

experiences and insights/learnings from the day’s activities

HSPs 22, 23 and 24

PTE Sub-team B

Day 3 AM PHO / Identified Venue

➢ Group Work: Consolidation of the results/findings of the LMT PTE. Refer to the accomplished Part III-A of the LMT PTE Checklist Kit (Annex B), and provide more details to complete the PTE results/findings.

➢ Overall consolidation of the LMT PTE results/findings using the recommended template provided in Annex C.

PTE Sub- teams A and B

Day 3 PM PHO; DOHRO

➢ Feedback to the P/CHO and DOHRO managers and technical staff to present to them the PTE results and findings.

➢ Enhancement of the EBF Strengthening Program Action Plans of the province and region by incorporating additional recommendations based on the LMT PTE results.

e. Transportation arrangements and provision of lunch/snacks for the PTE Team. The source of

funding for these items should also be identified during this meeting.

1.2. Coordinating the LMT PTE visits

The Provincial/City MCH/Nutrition Coordinator will be requested to coordinate the conduct of the LMT PTE visits with the hospitals/lying-in clinics to be visited. He/She should prepare the necessary communication letters of the Provincial/City Health Officer for the health facilities to be visited, and make the necessary follow-up calls to ensure that the health facility managers and trained HSPs will be available during the scheduled day and time of visits. For private hospitals, communication letters can be directed to the Head of the Hospital Breastfeeding Committee, with a copy to the chief/director of the hospital.

1.3. Materials to bring during the LMT PTE visits

The PTE Team will bring the following:

• Copies of the PTE for LMT Checklists (Annex A)

• Copies of the Summary Table of LMT PTE Results (Annex B)

• Copy of the LMT Facilitator’s manual

• List of hospitals and lying-in clinics to be visited and the list of names of trained HSPs for PTE in these health facilities

• Action Plans prepared during training by the HSPs to be followed up

• A hard copy of the following references:


- Ten Steps to Successful Breastfeeding (Annex C) - Breastfeeding Observation Job Aid (Annex D) - Executive Order No. 51, “Adopting a National Code of Marketing Breastmilk Substitutes,

Breastmilk Supplements and Related Products, Penalizing Violations Thereof and for Other Purposes.” (Annex E)

- DOH Administrative Order (AO) No. 2007-0026, “Revitalization of the Mother-Baby Friendly Hospital Initiative in Health Facilities with Maternity and Newborn Care Services” (Annex F)

- Republic Act No. 10028, “An Act Expanding the Promotion of Breastfeeding, Amending for the Purpose R.A. No. 7600, Otherwise Known as ‘An Act Providing Incentives to All Government and Private Health Institutions with Rooming-in and Breastfeeding Practices and for Other Purposes’.” (Annex G)

- Joint DOH-DOJ-DTI-DSWD AO No. 2012-0027, “Inter-Agency Committee Guidelines in the Exercise of their Powers and Functions as Stated in E.O. No. 51, series of 1986, otherwise known as “The National Code of Marketing of Breastmilk Substitutes, Breastmilk Supplements and Other Related Products, and its Revised Implementing Rules and Regulations.” (Annex H)

• Doll models

• Camera

2. Actual Conduct of the LMT PTE Visits On the scheduled dates, the LMT PTE Team will conduct the following activities:

2.1 Courtesy call

Pay a courtesy call to the head of the health facility and orient the facility managers and LMT-trained HSPs on the objective of the visit and the activities to be done during the visit.

2.2 PTE proper

Conduct the following PTE activities: a. Interview selected health facility managers, LMT-trained HSPs (includes review of

action plan to determine status of implementation) and their immediate supervisors; and pregnant/postpartum mothers.

b. Observe service provision: counseling of pregnant women on nutrition, risk of not breastfeeding; EBF counseling for postpartum mothers, assisting in the initiation of breastfeeding and managing problems related to breastfeeding; assisting non-breastfeeding women on the safe use of infant formula, when applicable. Take note of any findings related to the Milk Code violation within hospital/birthing clinic vicinity.

c. Observe the facility set-up to support the implementation of the “Ten Steps to Successful Breastfeeding,” including Milk code implementation and availability of a Lactation Station.

d. Review records related to the initiation of breastfeeding/EBF support. e. Provide coaching to the HSPs being assessed as needed. f. At the end of the PTE visit in each health facility, briefly summarize the PTE findings

using Part III-A of the LMT PTE Checklist Kit (Annex B). g. As a team, end each day with a meeting to discuss the experiences and

insights/learnings from the day’s activities.


2.3 Exit meeting with health facility managers and service providers

Conclude the PTE visit with a brief exit meeting with concerned health facility managers and service providers.

a. Discuss findings/identified problems among concerned service providers in applying

the knowledge and skills learned during training. b. Involve the health facility managers and service providers in formulating

recommendations/solutions. This will serve as a brief Action Planning using the MBFHI Implementation Improvement Plan matrix. (See LMT PTE Checklist Kit Part III-C in Annex B)

c. Assist them in reviewing and adjusting their action plans to improve MBFHI practices. d. List down agreed-upon next steps and sign together with the head of the

Hospital/Birthing Clinic Breastfeeding Committee. e. Thank the health facility managers and service providers for their support and

cooperation. f. Schedule with health facility manager/head of the Breastfeeding Committee the next

supervisory visit to assess whether agreements or recommendations had been successfully implemented or not.

3. Feedback to the P/CHO/DOHRO

3.1. Consolidation of the LMT PTE results/findings from all the visited health facilities

After all the health facilities targeted for PTE had been visited, the PTE Team should consolidate all the PTE results/findings from all the visited health facilities. The PTE Team should refer back to the accomplished Part III-A of the LMT PTE Checklist Kit (Annex B) for each of the visited health facilities, and provide more details to complete the PTE results/findings.

Annex C provides a suggested overall consolidation template for the LMT PTE results/findings. Copies of this accomplished table can be reproduced and distributed during the feedback meeting. A PowerPoint presentation can also be prepared from the consolidated report for the feedback meeting, to include pictures taken during the conduct of the LMT PTE at the visited health facilities.

3.2. Feedback Meeting with the P/CHO

The PTE Team should provide feedback on the PTE findings and recommendations to the P/CHO, and to the DOHRO if there are concerns that need to be addressed at the regional level. The feedback meeting will also be an opportunity for the PTE Team to discuss with the P/CHO the status of implementation of the “Ten Steps to Successful Breastfeeding” in each of the visited health facilities, focusing on the good practices, as well as the identified issues and concerns related to their work in support of breastfeeding.

The PTE Team should plan for the next follow-up visits, if needed or for continuing regular program monitoring and supportive supervision. It is also recommended that the Regional and Provincial/City MCH and Nutrition Coordinators make use of the LMT PTE results/recommendations in future planning and decision-making to enhance their respective EBF Strengthening Program.


IV. Orienting the LMT PTE Team on the PTE Set of Checklists Instructions for the PTE Team of LMT Trainers 1. This set or kit of PTE Checklists (refer to Annex B) is intended for use of the PTE Team,

composed of the LMT trainers, who conducted the training for the HSPs being followed up after training, to determine if the trained service providers are competently applying the knowledge and skills learned during training.

2. This set or kit of PTE Checklists includes the following:

Part I: Health Facility Profile. This form will provide basic information about the health facility, including the status of PhilHealth accreditation, issuance of a MBFHI Certificate of Commitment or MBFHI Accreditation, and information on staff training in lactation management. Part II. Assessing the Implementation of the Ten Steps to Successful Breastfeeding 1. Interview Questionnaires

1.1. For Health Facility Managers (Chief of Hospital/Director of Maternity Staff and other key

staff – Administrative Officer, Chief Nurse, Municipal Health Officer, Public Health Nurse). This interview questionnaire will help determine the level of support and commitment of the facility managers in implementing the “Ten Steps to Successful Breastfeeding”.

1.2. For Health Service Providers Trained in LMT (only one form for use in all three areas). This interview questionnaire will help assess if the trained HSPs are implementing the activities identified in the Action Plans that they developed during training. 1.2.1. Assigned at the Outpatient Department (OPD) for Antenatal Care (ANC) 1.2.2. Assigned at the Labor Room (LR) and Delivery Room (DR) areas 1.2.3. Assigned at the Obstetrical Ward

1.3. For Patients. These interview questionnaires will help determine the level of client satisfaction in terms of EBF information and counseling, and lactation management services received from the trained HSPs while at the health facility. 1.3.1. Pregnant women 1.3.2. Postpartum women

2. Service Provision Observation Checklists. These checklists provide an objective way of

assessing how the trained HSPs are applying the knowledge and skills learned during training related to EBF information-giving and counseling (listening and learning skills, building confidence and support), and lactation management services, as they attend to the pregnant and postpartum mothers in their respective health facilities.

2.1 Outpatient Department for Antenatal Care 2.2 Labor Room and Delivery Room areas; Neonatal Intensive Care Unit (NICU) 2.3 Obstetrical Ward 3. Facility Observation Checklists. These checklists will help generate information on the

availability of functional infrastructure/work spaces, equipment, instruments and other breastfeeding paraphernalia that are needed by the HSPs in order to provide quality health services related to lactation management services.

3.1 Outpatient Department for Antenatal Care


3.2 Labor Room and Delivery Room areas; Neonatal Intensive Care Unit 3.3 Obstetrical Ward 4. Records Review. The records review generates health facility data on the following

indicators: number of live births; number of newborns initiated to breastfeeding; number of infants 6-11 months of age seen to be exclusively breastfeeding until 6 months of age in the previous month (OPD records, RHU records); number of Caesarian section cases in the previous month (for CEmONC facilities only); number of infant deaths in the previous year; and number of maternal deaths in the previous year. If the health facility maintains an MCH/FP Facility Logbook, then the following indicators are also determined: number of pregnant and postpartum women provided with EBF information and counseling in the previous month.

Part III. Summary of Findings and Recommendations

A. Good Points: (Choose among items with “2” ratings) B. Assessment Scoring Results C. MBFHI Implementation Improvement Plan D. Participants:

1. Names, designation and place of assignment of trained HSPs 2. Names, designation and office of the LMT PTE Team members

The different checklists are designed to be stand-alone checklists, meaning that if one of the PTE Team members will be assigned, say at the Outpatient Department/Area, he/she can do all the tasks in that area, including interview of service providers trained in LMT, and observation of the trained service provider as he/she provides EBF counseling and support to pregnant women coming for antenatal care and postpartum mothers coming for follow-up, using the appropriate checklists. The PTE Team member can also accomplish the Facility Observation Checklist for the OPD while he/she is in this area. This facilitates the gathering of information using different methodologies from the same service provision area, and the PTE Team member can right away relate/triangulate the information gathered for easier analysis of the PTE findings.

3. The PTE Team members should always ask permission from the health facility managers and

trained service providers to be interviewed or observed. For pregnant and postpartum women to be interviewed, it is also necessary to inform them of the purpose of the interview (their responses will be useful to improve the quality of health services in the facility), and to ensure confidentiality (only their initials will appear in the questionnaire).

4. For each PTE Checklist, a scoring system is found at the last row, presented as:

Perfect Score: __= Number of questions x 2 (perfect rating). Exclude items with NA (not applicable) rating. Actual Score: ____ Percentage Score: Actual Score/Perfect Score x 100 = ____%

Example: 1. Interview Questionnaire for Health Managers (Chief Nurse interviewed) (Refer to Annex B) Perfect Score: Total number of questions = 10 x 2 (perfect rating) = 20

8 questions x 2 (rating given) = 16; 2 questions x 1 (rating given) = 2 Actual Score = 18


Percentage Score: 18/20 = 90%

In Part III, which is the Summary of Findings and Recommendations, there is a Summary Table to consolidate the Assessment Scoring Results.

Note that the scores obtained in the rating by methodology will only be used as guide for the trainers/monitors to find out where to focus the discussions on, which are items that need improvement most (items with scores of 0 and 1). In the feedback, the scores should not be discussed per se with the health facility managers and trained service providers. More importantly, the content of the feedback should first highlight the good points in the PTE findings (select from items with scores of 2), before going into a discussion of the items that need to be improved.

The PTE Team must keep in mind that the intention of this activity is to provide initial support and coaching to the trained HSPs to ensure that they are able to apply knowledge and skills in EBF counseling and assisting postpartum mothers in initiating and practicing EBF until six months of age, and continuing breastfeeding up to two years and beyond; The work environment of these trained HSPs should also be made supportive to the provision of quality breastfeeding management services and implementation of the “Ten Steps to Successful Breastfeeding”.

It is hoped that the regular conduct of the LMT PTE for all HSPs trained in LMT, with regular follow-up program monitoring and supportive supervision, will help ensure that the trained HSPs will be provided with the needed coaching and mentoring, from their trainers and later by their supervisors, to continually provide quality breastfeeding services in their respective health facilities. This is expected to increase EBF practice among mothers so that their babies will grow up to become healthy and productive citizens of the country.

5. The LMT PTE Team members should make a quick consolidation of their PTE findings, and sit

down with the health facility managers and trained service providers to discuss the PTE results and jointly formulate the MBFHI Implementation Improvement Plan for the health facility.

6. After the conduct of the LMT PTE in all the health facilities as planned, the PTE Team should

meet and consolidate their findings and formulate their next steps. A feedback should be provided to the P/CHO and to the DOHRO as appropriate.

7. For documentation and reporting purposes, the following are the expected LMT PTE Activity

Outputs:

• Number/percentage of hospitals/birthing clinics visited for the LMT PTE

• Number/percentage of HSPs among those trained in lactation management who were assessed to be providing quality basic breastfeeding management services


References Philippine Executive Order No. 51 on “Adopting a National Code of Marketing Breastmilk Substitutes, Breastmilk Supplements and Related Products, Penalizing Violations Thereof and for Other Purposes.” Department of Health. DOH Administrative Order 2007-0026 on the “Revitalization of the Mother-Baby Friendly Hospital Initiative in Health Facilities with Maternity and Newborn Care Services.” Philippine Republic Act No. 10028 on “An Act Expanding the Promotion of Breastfeeding, Amending for the Purpose R.A. No. 7600 Otherwise Known as ‘An Act Providing Incentives to All Government and Private Health Institutions with Rooming-in and Breastfeeding Practices and for Other Purposes’.” Joint Department of Health-Department of Justice-Department of Trade and Industry-Department of Social Welfare and Development Administrative Order 2012-0027 on the “Inter-Agency Committee Guidelines in the Exercise of their Powers and Functions as Stated in E.O. No. 51, series of 1986, otherwise known as “The National Code of Marketing of Breastmilk Substitute, Breastmilk Supplements and Other Related Products, and its Revised Implementing Rules and Regulations.” Department of Health. DOH Administrative Order 147 s. 2002. “Revised Guidelines Governing Health Human Resource Training and Development Programs.” Department of Health. DOH Memorandum 2012-0166. “Reiterating the Implementation of Level 1 to 4 Training Evaluation for Training Programs.” Department of Health, 2013. DOH HealthBeat. Special Edition for DOH-NCR: Protecting and Promoting Breastfeeding in Metro Manila. October 2013. World Health Organization and United Nations Children’s Fund, 2009. WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI). Section 1: Background and Implementation. World Health Organization and United Nations Children’s Fund, 2009. WHO/UNICEF BFHI. Section 3: Breastfeeding Promotion and Support in a Baby-Friendly Hospital – 20-hour Course. World Health Organization and United Nations Children’s Fund, 2009. WHO/UNICEF BFHI. Section 4: Hospital Self-Appraisal and Monitoring.


Annexes


Annex A: Post-training Monitoring and Evaluation (PTE)

Checklist Kit for Lactation Management Training (LMT) Part I: Health Facility Profile Date of Visit: __________ DOH Regional Office: ___________ Province: _________________ Provincial MBFHI Breastfeeding Coordinator: _________________________________________ Name of Hospital/Maternity Lying-in Clinic: ___________________________________________ Address: ____________________________ Classification: _____________ Bed capacity: _____ If a Maternity Lying-in Clinic: With PhilHealth Accreditation on: a. Newborn Care Package ___ Yes ___ No b. Maternity Care Package ___ Yes ___ No c. If accredited, is the facility able to get reimbursement for PhilHealth? ___ Yes ___ No MBFHI Certificate of Commitment issuance:

Date of issuance: _____________ Date of expiration: _______________ MBFHI Accreditation:

Date of issuance: _____________ Date of expiration: ______________

Information on Staff Trained in Lactation Management Training (LMT):

Name and Designation of Staff Trained in LMT

Area of Assignment

When Trained (Month &Yr.) and by What Agency

Action Plan Developed During Training

Available (Trained Service

Provider has a copy) (Check)

Status of Implementation of the Activities in the Action

Plan/Remarks

1.

2.

3.

4.

5.

Part II. Assessing the Implementation of the Ten Steps to Successful Breastfeeding 1. INTERVIEW QUESTIONNAIRES

1.1 Interview Questionnaire for Health Facility Managers (Chief of Hospital/Director of Maternity Staff and Other Key Staff – Administrative Officer, Chief Nurse, Immediate Supervisors, MHO, PHN) Name of Health Facility Manager: ______________________ Designation: ____________ Instruction: Tick (/) the appropriate box.


Key: 2=Yes 1=Yes, but needs improvement 0=No NA= Not applicable

2 1 0 NA Remarks

1. Is there a written breastfeeding policy approved and signed by the chief of hospital/maternity lying-in clinic head? (If there is, request for a copy).

2. Does the breastfeeding hospital/maternity lying-in clinic policy integrate the mother-friendly practices/10 Steps to Successful Breastfeeding? (If respondent is not aware of the 10 Steps, briefly describe).

3. Does the breastfeeding hospital/maternity lying-in clinic policy include the creation of a Breastfeeding Committee/Task Force for the facility?

4. If it does, is this Breastfeeding Committee functional? (Members meet regularly; meetings minutes filed; actively provide oversight to implement the Mother/Baby-Friendly Hospital Initiative.)

5. Is the breastfeeding hospital/maternity lying-in clinic policy or its part displayed in appropriate areas? If yes, in what areas of the facility is it posted? (E.g., Step 4: skin to skin contact – is displayed in the DR as a component of EINC.)

6. Do staff comply with the hospital/maternity lying-in clinic breastfeeding policy? How do you determine if the staff are compliant?

7. Have the service providers trained in Lactation Management Training (LMT) conducted an orientation for all other facility staff (including clinical staff, administrative staff, utility workers and security guards) on the MBFHI implementation, and on the breastfeeding policy of the facility?

8. Is there an existing mechanism to ensure that newly hired staff are likewise oriented on the breastfeeding health facility policy? (Must be done within the first six months of employment. Look for the orientation syllabus, schedule of orientation program and attendance.)

9. Is there a Lactation Station for use of lactating staff and women coming to the hospital/maternity lying-in clinic? If not yet certified or still with no COC, please share with us the plan of the management regarding this

Thank the respondent. Perfect Score: 20 (Exclude items with NA ratings) Score: _____ % Score (Score/20 x 100): _____

Summary of Good Points and Issues/Concerns to Be Discussed During Feedback:

Name/Signature of Interviewer:_____________________________


1.2 Interview Questionnaire for Health Service Providers Trained in LMT 1.2.1 Assigned at the Outpatient Department (OPD) for Antenatal Care (ANC) 1.2.2 Assigned at the Labor Room (LR) and Delivery Room (DR) Areas 1.2.3 Assigned at the Obstetrical Ward

Name of Trained Service Provider: _______________________ Designation: ____________ Area of Assignment: ___ OPD: ___ DR/LR/NICU: ___ OB Ward: ___ Others: ____________ Instruction: Tick (/) the appropriate box. Key: 2=Yes 1=Yes, but needs improvement 0=No NA= Not applicable

2 1 0 NA Remarks

1. Do you have a copy of the Action Plan that you have developed during the LMT? (If the answer is yes, request the respondent to bring out his/her copy; If the answer is no, bring out your copy of his/her Action Plan.)

2. Have you started implementing the activities in your Action Plan? (Discuss with him/her the status of implementation of the activities listed in his/her Action Plan.)

3. Since you have undergone the three-day LMT Course, have you oriented your colleagues in this facility (including other clinical staff, administrative staff, utility workers and security guards) on the MBFHI implementation, and on the breastfeeding policy of the facility? If you have not done so, what do you plan to do to carry out this task?

4. Is there a hospital/maternity lying-in clinic breastfeeding policy? (If the response is yes, ask the trained service provider to briefly describe the process of this policy development, and his/her role in its preparation. If there is no policy ask him/her what he/she plans to do to have one for the facility. If there is a policy, ask for a copy.

5. Is there a Breastfeeding Committee?

6. If there is, is it functional? (Members meet regularly; meetings minutes filed; actively provide oversight to implement the Mother/Baby Friendly Hospital Initiative.)

7. Do you record the EBF information-giving and counseling services that you provide to your patients in the MCH/FP Logbook??

8. Do you have IEC materials on EBF or video on “First Hour” or initiation of breastfeeding for mothers to watch?

9. Do you find the activities that you have identified in your Action Plan doable/easy to implement? If no, what are the difficulties that you have encountered in implementing the activities in your Action Plan, and how did you address them; do you plan to address them?





1.3 Interview Questionnaire for Patients 1.3.1 Pregnant Women

Initials of Patient: ___________ Address: ______________________________________________ Instruction: Tick (/) the appropriate box. Key: 2=Yes 1=Yes, but needs improvement 0=No NA= Not applicable

2 1 0 NA Remarks

1. During your visit to this facility for prenatal care or for other health reasons while you are pregnant, were you asked how you plan to feed your newborn after delivery? (Note her feeding plan.)

2. Were you informed on the benefits of breastfeeding and the harmful effects of not breastfeeding? If Yes, can you mention them?

3. Were you taught to demand “skin-to-skin” contact and initiation of breastfeeding right after delivery during your prenatal visit in this facility?

4. Did the health staff demonstrate proper positioning and correct attachment? (Refer to the breastfeeding job aid.) If yes, What positions do you remember were mentioned?

5. Can you tell me if the health staff was kind and respectful while talking to you?

6. Did he/she avoid use of judging words? (E.g., “You are not a good mother if you will not breastfeed your baby.”)

7. Did he/she praise/acknowledge things that you were doing right? (E.g., “You said that when you had your first baby, you breastfed him even if you had difficulty.”)

8. Did he/she provide you with practical help? (E.g., “Eating well-balance meals will be beneficial for you and your baby.”)

9. Did he/she make one or two suggestions, not commands? (E.g., “I suggest that when you have delivered your baby, you take a bath every day and you do not need to do special washing of your breast using soap or creams.”)

10. Were you informed that you are not supposed to accept free infant formula, bottles, artificial teats and other paraphernalia or gifts that may undermine breastfeeding as this is a Milk Code violation? If yes, what were you told?

11. Were you encouraged by the health staff to ask questions? What did you ask?

12. Overall, are you happy/satisfied with the way the health staff provided you with prenatal care?


Summary of Good Points and Issues/Concerns to Be discussed During Feedback:



1.3 Interview Questionnaire for Patients 1.3.2 Postpartum Women

Initials of Patient: ___________ Address: ______________________________________________ Instruction: Tick (/) the appropriate box. Key: 2=Yes 1=Yes, but needs improvement 0=No NA= Not applicable

2 1 0 NA Remarks

1. Did you start breastfeeding your newborn right after delivery? (Congratulate mother if she is breastfeeding her baby. If not, ask for the reason.)

2. Were you asked how you plan to feed your newborn after discharge? If yes, what will you feed your baby?

3. Did the health staff examine your breast for any possible problem?

4. Were you also asked if you had breast surgery before?

5. Did the health staff show interest by asking about you and your baby? (E.g., “How is feeding going on with you and your baby?”) Did the health staff call you and your baby by your first names?

6. Did health staff demonstrate proper positioning and correct attachment to facilitate breastfeeding? (Refer to the breastfeeding job aid.)

7. If your baby is being given supplements/replacement feeds, what is the reason?

8. If your newborn is confined at the NICU, were you informed of the schedule of breastfeeding at the NICU?

9. Can you tell me if the health staff was kind and respectful while talking to you?

10. Did he/she avoid use of judging words? (E.g., “You are not a good mother if you do not breastfeed your baby.”)

11. Did he/she praise/acknowledge things that you were doing right? (E.g., “You are breastfeeding your baby even if you have difficulty”; “You called the nurse for assistance when you had difficulty feeding your baby.”)

12. Did he/she provide you with practical help? (e.g., placed a pillow on your lap to support the baby while you were breastfeeding, etc.)

13. Did he/she make one or two suggestions, not commands? (E.g., “I suggest that you take a bath every day and you do not need to do special washing of your breast using soap or creams.”)

14. Were you informed that you are not supposed to accept free infant formula, bottles, artificial teats and other paraphernalia or gifts that may undermine breastfeeding as this is a Milk Code violation? If yes, what were you told?

15. Were you encouraged by the health staff to ask questions? What did you ask?

16. Overall, are you happy/satisfied with the way the health staff provided care for you and your newborn?

Thank the respondent. Perfect Score: 32(Exclude items with NA ratings) Score: _____ % Score (Score/32 x 100): _____




2. SERVICE PROVISION OBSERVATION CHECKLISTS 2.1. Outpatient Department (OPD) for Antenatal Care (ANC) Name of Trained Service Provider: ____________________________ Designation: ____________ Instruction: Tick (/) the appropriate box. Key: 2=Yes 1=Yes, but needs improvement 0=No NA= Not applicable

2 1 0 NA Remarks

1. Provides pregnant women with information on the benefits of breastfeeding.

2. Demonstrates to pregnant women proper positioning and correct attachment (Refer to the breastfeeding job aid.)

3. Counsels pregnant women on demanding the “skin-to-skin” contact with her baby immediately after delivery to initiate breastfeeding.

4. Conducts breast examination to check for possible breastfeeding problems.

5. Provides IEC flyers on breastfeeding to mothers.

6. Provides the mothers with a Mother and Baby Book from the DOH and not one produced by milk companies.

7. Counseling Process: Listening and Learning Skills

7.1 Uses helpful nonverbal communication.

7.2 Asks open-ended questions.

7.3 Shows interest and reflects back on what the mother says.

7.4 Empathizes to show that he/she understands the mother’s feelings.

7.5 Avoids words that sound judging.

8. Counseling Process: Building Confidence and Giving Support

8.1 Recognizes and acknowledges what a mother and baby are doing right.

8.2 Gives practical help.

8.3 Gives a little relevant information using suitable language.

8.4 Makes one or two suggestions, not commands.

8.5 Arranges for follow-up and support suitable to the mother’s situation.





2.2. Labor Room (LR) and Delivery Room (DR) Areas; Neonatal Intensive Care Unit (NICU) Name of Trained Service Provider____________________________ Designation: _____________ Instruction: Tick (/) the appropriate box. Key: 2=Yes 1=Yes, but needs improvement 0=No NA= Not applicable

2 1 0 NA Remarks

1. Service provider is cordial and respectful in talking to the patients.

2. Allows women to have a companion of their choice if desired during labor and delivery.

3. Ensures the patients wear hospital/facility gowns with opening in front to facilitate breastfeeding.

4. In the LR, allows women in labor to walk around with assistance and with coaching from him/her or a companion of choice.

5. In the LR, allows women to drink/eat light food items.

6. Ensures that the use of pain relief, anesthesia or any drugs that may affect breastfeeding is practiced only if necessary.

7. Ensures that invasive procedures like rupture of the membranes, episiotomies, acceleration/induction of labor, instrumental and surgical deliveries are not done unless there are indications; and that the patient is counseled before any of these procedures is done on her.

8. At the DR, if the service provider is the birth attendant/part of the DR team, he/she immediately dries the baby with a piece of cloth upon delivery.

9. Places the baby on the mother’s abdomen “skin-to-skin” within 60 minutes without interruption to initiate breastfeeding.

10. Cuts the umbilical cord after the pulsation stops (2-3 minutes after delivery).

11. Observes for breastfeeding cues and offers help when needed.

12. Wraps the baby with the mother safely when necessary (to keep mother and baby skin-to-skin) when no one is available to look after the mother and baby after delivery.

At the NICU:

13. The trained service provider offers help to mothers to initiate lactation and keep milk supply within 6 hours after delivery of the baby (he/she inspects the mothers’ breasts for engorgement, does back massage, etc.)

14, Shows hand expression of breast milk and tells mothers that they need to breastfeed or express breast milk for at least 6-8 times in 24 hours to keep up their breast milk supply.

15. Assists the mothers in feeding their newborns with breast milk by cup/tube.

16. Informs mothers on the risks of not breastfeeding and the benefits of various feeding options as well as proper care of their breasts.

Thank the respondent. Perfect Score: 32 (Exclude items with NA ratings) Score: ___ % Score (Score/32 x 100): _____




2.3. Obstetrical Ward Name of Trained Service Provider: ____________________________ Designation: ____________ Instruction: Tick (/) the appropriate box. Key: 2=Yes 1=Yes, but needs improvement 0=No NA= Not applicable / Not observed

2 1 0 NA Remarks

1. Service provider is cordial and respectful in talking to the patients.

2. Ensures the patients wear hospital/facility gowns with opening in front to facilitate breastfeeding.

3. Can recognize if mothers know that their babies are hungry and want to feed. Checks if mothers can identify feeding cues.

4. Teaches the mothers proper positioning and correct attachment.

5. Inspects the mothers’ clothing that may interfere with breastfeeding.

6. Demonstrates/teaches mothers hand expression, cup feeding and proper milk storage. Shows hand expression of breast milk and tells mothers that they need to breastfeed or express breast milk for at least 6-8 times in 24 hours to keep up their breast milk supply.

7. Informs mothers on the proper care of their breasts.

8. Informs mothers who cannot breastfeed, or decided not to breastfeed, of the hazards of not breastfeeding and the management of various feeding options; and helps them to decide on the most suitable option in their situations. (e.g., getting pasteurized milk from the Milk Bank, etc.)

9. If a mother decides not to breastfeed, demonstrates how to appropriately and safely prepare the feeding option to the mother; asks for a return demonstration from the mother.

10. If a baby is given supplements/replacement feeds due to a medical condition, records the reasons for supplement/replacement feed in baby’s chart/record. Indicates if the baby is fed by bottle, cup/spoon.

11. Counseling Process: Listening and Learning Skills

11.1 Uses helpful nonverbal communication.

11.2 Asks open-ended questions.

11.3 Shows interest and reflects back on what the mother says.

11.4 Empathizes to show that she understands the mother’s feelings.

11.5 Avoids words that sound judging.

12. Counseling Process: Building Confidence and Giving Support

12.1 Accepts what the mother thinks and feels.

12.2 Recognizes and acknowledges what a mother and baby are doing right.

12.3 Gives practical help.

12.4 Gives a little relevant information using suitable language.

12.5 Makes one or two suggestions, not commands.

12.6 Arranges follow-up and support suitable to the mother’s situation, including referral to the RHU-MCH/BHS to link the mother to a Breastfeeding Support Group (BFSG).

Thank the respondent. Perfect Score: 24 (Exclude items with NA ratings) Score: ___ % Score (Score/24 x 100): _____




3. FACILITY OBSERVATION CHECKLISTS 3.1. Outpatient Department (OPD) for Antenatal Care (ANC)

Instruction: Tick (/) the appropriate box. Key: 2=Yes 1=Yes, but needs improvement 0=No NA= Not applicable

2 1 0 NA Remarks

General Observations:

1. With client waiting area.

2. Clinic and surroundings are clean.

3. Toilet facilities available.

4. Running water available.

5. Adequate room lighting.

6. Airy room with electric fan or air conditioner.

7. With chairs/benches enough for women to sit comfortably in the waiting area of the OPD.

8. Curtains or movable divider to provide privacy available in the ANC Room.

9. Poster or tarpaulin on the “Ten Steps to Successful Breastfeeding” incorporating hospital/facility policy appropriately and strategically displayed in the OPD/ANC Clinic area.

10. IEC materials that conform with the standard BF messages available (initiate breastfeeding within the first hour of birth, exclusive breastfeeding for the first six months of life, continue breastfeeding while introducing complementary feeding at six months and beyond).

11. There are no equipment, articles and materials donated/sponsored by milk companies in the OPD-ANC Clinic area. (e.g., weighing scale, height chart, linens, clock, poster, flyer, mother-baby book, sample milk for pregnant women, etc.)

12. There are no milk company representatives seen around. If there are, what do they do in this area?

13. There are no other Milk Code violations observed around. If there are, what are these violations?

Breastfeeding Area for Health Facility Staff and Women Coming to the Facility:

14. Available Breastfeeding Room/Lactation Station for Women Employees (Basic Requirements from RA 10028 and IRR, “ Guidelines for Mother/Baby-Friendly Workplace Certification)

15. Well-lighted and clean area.

16. Available chairs, sofa with backrest spacious enough for at least two to four mothers at a time.

17. Easily accessible nearby lavatory for hand washing.

18. Towel/paper towels available.

19. Electric fan or air conditioner.

20. Cooler/refrigerator solely for expressed breast milk storage.

21. Covered plastic cups available.

22. Wall clock.

23. Small table.

24. Covered trash can.

25. Manual breast pump.

26. Electrical outlets in case electronic breast pump is available.

Thank the respondent. Perfect Score:52 (Exclude items with NA ratings) Score:___ % Score (Score/52 x 100): ____




3.2. Labor Room (LR) and Delivery Room (DR) Areas; Neonatal Intensive Care Unit (NICU) Instruction: Tick (/) the appropriate box. Key: 2=Yes 1=Yes, but needs improvement 0=No NA= Not applicable

2 1 0 NA Remarks


1 LR and DR Areas are clean.

2. LR and DR are restricted areas as part of infection prevention.

3. Toilet facilities available at the Labor Room.

4. Running water available at the LR and DR.


6. Air conditioner/electric fan available at the LR.

7. Air conditioner available at the DR.

8. Spacious LR that allows movement of the women in labor.

9. In the LR, aside from comfortable beds with railings, there are chairs that the women in labor and their companions may use.

10. Supplies of the following are available for use of staff at the DR:

• Scrub suits

• Head caps

• Masks

• Goggles

• Slippers

• Aprons

• Gloves

• Linen cloths to wipe dry newborns

• Blankets to cover the mothers and newborns

• Patient gowns with front opening are also available for the patients.

11. In the LR, available poster on the health facility policy to support the initiation of breastfeeding soon after delivery (e.g. Emotional support during labor, attention on the effects of pain medications on the baby, offering light food and fluids during labor, freedom of movement during labor, avoidance of unnecessary CS, early mother-baby contact, facilitating the first feed).

12. Other IEC materials (posters) that conform with the standard BF messages available (initiate breastfeeding within the first hour of birth, exclusive breastfeeding for the first six months of life, continue breastfeeding while introducing complementary feeding at six months and beyond).

13. There are no equipment, articles and materials donated/sponsored by milk companies in the LR and DR areas (e.g., weighing scale, linens, clock, poster, etc.)


15. At the NICU, cups and tubes are available to use in feeding newborns with breast milk.

16. At the NICU, there are no bottles and teats/pacifiers.

Thank the respondent. Perfect Score:32 (Exclude items with NA ratings) Score:___ % Score (Score/32 x 100): ____




3.3. Obstetrical Ward Instruction: Tick (/) the appropriate box. Key: 2=Yes 1=Yes, but needs improvement 0=No NA= Not applicable

2 1 0 NA Remarks


1. Obstetric Ward area is clean.

2. Toilet facilities available.

3. Running water available.


5. Airy room with electric fan or air conditioner.

6. With comfortable beds with railings for postpartum women and their newborn babies.

7. Chairs are available for postpartum women who may want to breastfeed their babies in sitting position.

8. Curtains/movable divider to provide privacy.

9. Poster or tarpaulin on the “Ten Steps to Successful Breastfeeding” incorporating hospital/facility policy appropriately and strategically displayed in the ward area.

10. IEC materials that conform with the standard BF messages available (initiate breastfeeding within the first hour of birth, exclusive breastfeeding for the first six months of life, continue breastfeeding while introducing complementary feeding at six months and beyond).

11. There are no equipment, articles and materials donated/sponsored by milk companies in the Obstetric Ward area. (e.g., weighing scale, height chart, linens, clock, poster, flyer, mother-baby book, feeding bottles and artificial teats, sample artificial formula milk, etc.)


Breastfeeding Area for Health Facility Staff and Postpartum Patients

13. Available Breastfeeding Room/Lactation Station for Women Employees (Basic Requirements from RA 10028 and IRR, “ Guidelines for Mother/Baby-Friendly Workplace Certification)

14. Well-lighted and clean area.

15. Available chairs, sofa with backrest spacious enough for at least two to four mothers at a time.

16. Easily accessible nearby lavatory for hand washing.

17. Towel/paper towels available.

18. Electric fan or air conditioner.

19. Cooler/refrigerator solely for expressed breast milk storage.

20. Covered plastic cups available.

21. Wall clock.

22. Small table.

23. Covered trash can.

24. Manual breast pump.

25. Electrical outlets in case electronic breast pump is available.

Thank the respondent. Perfect Score: 50 (Exclude items with NA ratings) Score:___ % Score (Score/50 x 100): ____




4. RECORDS REVIEW 4.1 Health Facility Data

Program Indicator Number Program Indicator Number

No. of live births (previous month) Number of Caesarian Section cases (previous month); (for CEmONC facilities only)

No. of newborns initiated to BF(previous month)

No. of infant deaths (previous year)

No. of infants 6-11 months of age seen to be exclusively breastfeeding until 6 months of age (previous month) (OPD Records)

No. of maternal deaths (previous year)

4.2 Review of the MCH-FP Facility Logbook that includes information on the names of pregnant and postpartum women provided with EBF information or counseling.

1. Do the trained service providers maintain an MCH-FP Facility Logbook where they also record information on the names of pregnant and postpartum women provided with EBF information or counseling? ___Yes ___No

2. Is the MCH-FP Facility Logbook updated? ___Yes ___ No 3. How many women were provided with EBF information or counseling in the previous

month?

Month and Year: _______________ (Total) No. of pregnant women provided with EBF information or counseling = _________ No. of postpartum women provided with EBF information or counseling = _______

Part III. Summary of Findings and Recommendations: (Use the back space if necessary to complete the PTE summary of findings.) III. A. Summary of Assessment Scoring Results

LMT PTE Methodology Perfect Score

(Exclude Items with NA Rating)

Actual Score

% Score (Actual Score

Divided by Perfect Score x 100)

1. Interviews

1.1. with HF Managers 20

1.2 Interviews with Health Service Providers Trained in LMT

1.2.1 Assigned at the Outpatient Department (OPD) for Antenatal Care (ANC)

18

1.2.2 Assigned at the Labor Room and Delivery Room Areas

18

1.2.3 Assigned at the Obstetric Ward 18

1.3 Interviews With Patients

1.3.1 With Pregnant Women 24

1.3.2 With Postpartum Mothers 32

2. Service Provision Observation

2.1 of Trained Service Providers at the OPD for ANC

18

2.2 of Trained Service Providers at the LR and DR Areas; and NICU

32


2.3 of Trained Service Providers at the Obstetrical Ward

24

3. Facility Observation

3.1 At the OPD for ANC 52

3.2 At the LR and DR Areas; and NICU 32

3.3. At the Obstetrical Ward 50

TOTAL (Add scores only for

checklists used during the visit)

Notes: III. B. Good Points (Select from items with scores of 2) _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ III. C. MBFHI Implementation Improvement Plan

Issues Recommendations Agreements

III. D. Participants

Name of LMT-trained Service Provider Followed Up

Designation and Area of Assignment Signature

1.

2.

3.

4.

5.


Name of LMT Trainer Conducting the PTE

Designation and Office Signature

1.

2.

3.

4.

5.

Name of LMT TOT Trainer Observing the PTE

Designation and Office Signature

1.

2.

3.

4.

5.


Annex B: Summary Table of LMT PTE Results Province: _______________________________ Date of Activity: _________________

NAME OF FACILITY & ADDRESS

GOOD POINTS

ISSUES/CONCERNS ACTIONS TAKEN/ RECOMMENDATIONS

TIME FRAME

PERSONS RESPONSIBLE

DAY 1 - Date:

Health Facility 1:

Health Facility 2:

Health Facility 3:

Health Facility 4:

DAY 2 - Date:

Health Facility 5:

Health Facility 6:

Health Facility 7:

Health Facility 8:


Annex C: The Ten Steps to Successful Breastfeeding - A Joint

WHO/UNICEF Statement

Every facility providing maternity services and care for newborn infants should: 1. Have a written breastfeeding policy that is routinely communicated to all health care staff.

2. Train all health care staff in skills necessary to implement this policy.

3. Inform all pregnant women about the benefits and management of breastfeeding.

4. Help mothers initiate breastfeeding within an hour of birth.

5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.

6. Give newborn infants no food or drink other than breast milk unless medically indicated.

7. Practice rooming-in: Allow mothers and infants to remain together 24 hours a day.

8. Encourage breastfeeding on demand.

9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.

10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.


Annex D: Breastfeed Observation Aid Mother's name _______________________________ Date ___________________

Baby's name _________________________________ Baby's age ______________

Signs that breastfeeding is going well: Signs of possible difficulty:

GENERAL

Mother: Mother: Mother looks healthy Mother looks ill or depressed Mother relaxed and comfortable Mother looks tense and uncomfortable Signs of bonding between mother and baby No mother/baby eye contact Baby: Baby: Baby looks healthy Baby looks sleepy or ill Baby calm and relaxed Baby is restless or crying Baby reaches or roots for breast if hungry Baby does not reach or root BREASTS Breasts look healthy Breasts look red, swollen, or sore No pain or discomfort Breast or nipple painful

Breast well supported with fingers away from nipple Breasts held with fingers on areola

Nipple protractile Nipple flat, not protractile BABY’S POSITION Baby’s head and body in line Baby’s neck and head twisted to feed Baby held close to mother’s body Baby not held close Baby’s whole body supported Baby supported by head and neck only

Baby approaches breast, nose to nipple Baby approaches breast, lower lip/chin to nipple

BABY’S ATTACHMENT More areola seen above baby’s top lip More areola seen below bottom lip Baby’s mouth open wide Baby’s mouth not open wide Lower lip turned outwards Lips pointing forward or turned in Baby’s chin touches breast Baby’s chin not touching breast SUCKLING Slow, deep sucks with pauses Rapid shallow sucks Cheeks round when suckling Cheeks pulled in when suckling Baby releases breast when finished Mother takes baby off the breast Mother notices signs of oxytocin reflex No signs of oxytocin reflex noticed

Notes:

WHO/UNICEF BFHI Section 3: Breastfeeding promotion and support in a baby-friendly hospital – 20-hour course 2009


Annex E:


Annex F:


Annex G:


Annex H:

conduct of post-training evaluation on lactation ......conduct of post-training evaluation on...

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