MOCK RE-ASSESSMENT BABY FRIENDLY HOSPITAL INITIATIVE

HOSPITAL TUANKU MIZAN

12/6/2015

ASSESSORS :
1.KJ NAPSIAH BT OTHMAN
2.KJ ZUIDAH BT ISMAIL
3.KJ(KUP) SARIPAH SARINGAT
4.KJ(KUP)FAZIAH BT ISMAIL
5.KJ(KUP) FATIMAH BT SHARIF
6.KJ(KUP) RAHMARYATI BT ABD RAHMAN
7.KJ(KUP) ROSLIA BT M.ENGGOH
8.JM ANGELAI DEVI A/P AHVELI
9.JM NURUL HUSNA BT MANSOR

STEP 1 : Have a written breastfeeding policy that is

routinely communicated to all health care staff
Bil

Items

Compliance

1.1

A written BF or infant feeding policy for the hospital exists and is

attached

Yes

1.2

The policy covers the 10 steps to successful breastfeeding

adequately

Yes

1.3

The policy upholds the International Code of Marketing of Breastmilk Substitutes

Yes

1.4

The policy requires that HIV-positive mothers receive counseling ,

including information about the advantages and disadvantages of
various infant feeding options and specific guidance in selecting
the options likely to be suitable for their situations, supporting
them in their choices

No

1.5

A summary of the policy is displayed at the targeted area

Yes

1.6

The summary of the policy is displayed in language(s) and

written with wording most commonly understood by both
mothers and staf

Yes

STEP 1 : Have a written breastfeeding policy that is

routinely communicated to all health care staff
Summary
Facility completely meets the Baby-friendly criteria
for Step 1
Achievements

Meet criteria

Improvements required

No

Improvements recommended

No

Yes

Step 2 :Train all health care staff

No.

Item

Compliance

2.1

A written curriculum for training in breastfeeding promotion and

support is available

Yes

2.2

Step 1 and 3-10 and the Code are adequately covered in the
training

Yes

2.3

Training records indicate that 80% of the appropriate clinical

staf received training at least 20 hours in duration with at least
of supervised clinical experience as part of it

Yes

2.4

Training records also indicate that 80% of appropriate nonclinical staf received appropriate training on the BFHI and their
roles in providing breastfeeding support for mothers

Yes

2.5

The 20-hour course or another training activity provides training

on supporting the non-breastfeeding mother

Yes

2.6

A review on the training curriculum indicates that it covers the

topics on supporting the non-breastfeeding mother adequately

Yes

2.7

The types and percentage of staf receiving training on

supporting the non-breastfeeding mother are adequate, given
the facilitys needs

Yes

Step 2 :Train all health care staff

No.

Item

Compliance

2.8

The staf interviewed confirmed that they received training on

breastfeeding and Baby-friendly practices at least 20 hours in
total including at least 3 hours of supervised clinical training, or
if on the job less than 6 months, received orientation on the
policy

100%

2.9

The staf interviewed were able to answer 4 out of 5 questions

on breastfeeding support and promotion correctly

100%

The staf interviewed can described 2 issues that should be

discussed with a pregnant woman if she indicates that she is
considering giving her baby something other than breastmilk

100%

2.10

Step 2 :Train all health care staff

Summary :
Facility completely meets the Baby-friendly criteria
for Step 2
Achievements
Improvements required
Improvements recommended

Meet criteria

Yes

Step 3 : Inform all pregnant women about

breastfeeding
No.

esItem

Compliance

3.1

The mothers interviewed reported that a staf member has

talked with them individually or ofered a group talk that
included information about breastfeeding, as part of their
antenatal care

Yes

3.2

The mother interviewed could recalled basic information

presented or discussed with them on at least 2 out of 3
topics

Yes

Step 3 : Inform all pregnant women about

breastfeeding
Summary :
Facility completely meets the Baby-friendly criteria
for Step 3
Achievements
Improvements required
Improvements recommended

Meet the criteria

Yes

Step 4: Help mother initiate BF

No.

Item

Compliance

4.1

Mothers with vaginal birth ,LSCS without GA and LSCS with GA

Yes

4.2

Mothers reported that their babies were given to them

immediately or within 5 minutes after birth or, if not, the delay
in contact was medically justified

Yes

4.3

Mothers reported that they had their babies with them, skin-toskin that first time for 60 min or more without separation or the
baby was separated from the mother or contact ended for a
justified medical reason

4.4

Mothers reported that they were encouraged to look for signs

for when their babies were ready to feed and ofered help with
bf

4.5

Mothers with babies in Special Care reported that they have

had a chance to hold their babies skin-to-skin or, if not , the
staf gave justifiable reasons why they could not

Yes

Yes

Baby
admitted
NICU for
premature
baby

Step 4: Help mother initiate BF

Summary :
Facility completely meets the Baby-friendly criteria
for Step 4
Achievements
Improvements required
Improvements recommended

Na

Step 5 : Show mothers how to BF, and how to

maintain lactation
No.

Item

Compliance

5.1

% of staf managed to demonstrate how to prepare and feed

BMS accurately, completely and included the mother giving a
return demo

100%

5.2

Staf reported that they teach mothers about positioning and

attachment and describe correct techniques for both or, if they
do not teach, describe to whom to refer mothers on their shifts

100%

5.3

Staf reported that they teach mothers hand expression and

give adequate descriptions and demonstrations of what they
would teach mothers or, if they do not teach ,describe to whom
to refer mothers on their shifts

100%

5.4

Staf reported that they teach mothers who are not BF how to
prepare their feeds and describe adequately what they would
discuss or, if they do not teach ,describe to whom to refer
mothers on their shift

Na

Step 5 : Show mothers how to BF, and how to

maintain lactation
No.

Item

5.5

Mothers reported that if they are BF, staf ofered further

help with BF the next time the baby was fed or within 6
hours of delivery

Yes

5.6

Mothers reported that if they are BF, staf ofered help with
positioning and attaching their babies for BF

Yes

5.7

Mothers are able if they are BF, to demonstrate and/or

describe correct positioning

5.8

Mothers are able ,if they are BF, to describe signs that
would indicate their babies are latched on ( or attached )
and suckling well

Compliance

Yes

Yes

Step 5 : Show mothers how to BF, and how to

maintain lactation
bil

item

% of compliance

5.9

Mothers reported , if they are BF, someone on the staf

has either ofered to show them how to express their
milk by hand or given them written information and told
them where they could get help, if needed

100%

5.10

Mothers reported, if they have decided not to BF, the

staf has ofered to show them how to prepare and give
their babies feeds and they can describe adequate
advice or report that they did not want help

Na

5.11

Mothers reported, if they have decided not to BF, they

were asked to prepare a feed themselves with the staf
member watching

Na

Step 5 : Show mothers how to BF, and how to

maintain lactation
No.

item

compliance

5.12

Mothers in Special care reported, if they are BF or

intending/planning to do so, they have been ofered help to
start their Breast milk coming and to keep up the supply
within 6 hours of their babies births

Yes

5.13

Mothers in Special care reported, if they are BF or

intending/planning to do so, they have been shown how to
express their milk by hand or did not want this help

Yes

5.14

Mothers in Special care, if they are BF or intending/planning

to do so, to describe and demonstrate how they were shown
to express their milk

Yes

5.15

Mothers in Special care, if they are BF or planning to do so,

they have been told they need to BF or express their milk 6
times or more every 24 hours to keep up the supply

Yes

Step 5 : Show mothers how to BF, and how to

maintain lactation
Summary :
Facility completely meets the Baby-friendly criteria
for Step 5
Achievements

Improvements required
Improvements recommended

Na

Not enough demonstration could be observed

for an accepted reason.
All staf can show the positioning, attachment
of breastfeed and also hand expression to
mother.

Step 6 : Give newborn infants no food or drink

other than breast milk
bil

item

compliance

6.1

Hospital data indicates that at least 75 % of the full-term babies

delivered in the past year were exclusively BF or fed human milk
from birth to discharge, or, if they received any feeds other than
breast human milk this was because of documented medical
reason, or mothers informed choices

Yes

6.2

The hospital has an adequate facility/space and necessary

equipment for giving demonstrations of how to prepare formula
and other feeding options away from BF mothers

Yes

6.3

Observations in the postpartum wards/rooms and any well baby

observation areas showed that :
For __out of __ babies observed, the babies were fed only breast
milk, or there were acceptable medical reasons or informed
choices for receiving something else

Na

Step 6 : Give newborn infants no food or drink

other than breast milk
bil

item

compliance

6.4

Mothers reported that their babies had received at least some

breast milk or they were planning to BF

Yes

6.5

Mothers reported that their babies had received only breast

milk or if they had received anything else , it was for a justified
medical reason

Yes

6.6

Mothers reported, if they have decided not to BF , that the staf

have discussed with them the various feeding options & were
able to describe at least 1 thing that was discussed to help
them to decide what was suitable in their situations or said
they did not want the information

Na

6.7

Mothers in Special care reported that if they are not planning to Yes
BF, staf has talked with them about risks and benefits of
various feeding options

Step 6 : Give newborn infants no food or drink

other than breast milk
Summary :
Facility completely meets the Baby-friendly criteria
for Step 6
Achievements

Improvements required
Improvements recommended

Yes

Step 7: Practice rooming in

bil

item

compliance

7.1

Observations in the post partum wards /rooms and any well baby
observations areas showed that : the babies and mothers were
together rooming in or, if not, had justifiable reasons for being
separated not being together

Yes

7.2

Mothers reported that their babies were always been in the

same room with them or, if separated ,it was for a justified
reason.

Yes

Step 7: Practice rooming in

Summary :
Facility completely meets the Baby-friendly criteria
for Step 7
Achievements

Improvements required
Improvements recommended

Yes

Step 8: Encourage BF on demand

bil

item

compliance

8.1

Breastfeeding mothers could described at least 2 things

they were told by the staf about how to recognize if their
babies were hungry

Yes

8.2

Postnatal mothers reported that they had been advised by

the staf to feed their babies for as often and as long as the
babies wanted or something similar

Yes

Step 8: Encourage BF on demand

Summary :
Facility completely meets the Baby-friendly criteria
for Step 8
Achievements
Improvements required
Improvements recommended

Yes

Step 9 : Give no artificial teats or pacifiers to BF

infants
bil

item

compliance

9.1

Observation in the postpartum wards/rooms and any well baby

observation areas showed that the babies were not using bottles
and teats or, if they were, their mothers had been informed of the
risks

yes

9.2

Postpartum mothers reported that their babies were not fed any
fluids in bottles with teats , as far as they knew

Yes

9.3

Postpartum mothers reported that their babies have not sucked

on pacifiers as far as they knew

Yes

Step 9 : Give no artificial teats or pacifiers to BF

infants
Summary :
Facility completely meets the Baby-friendly criteria
for Step 9
Achievements
Improvements required
Improvements recommended

Yes

Step 10:Foster the establishment of BF support

groups and refer mothers to them
bil

item

compliance

10.1

Postpartum mothers report that they have been given

information on how and where to get help with feeding their
babies after return home and can mention one type of help
available

No

Step 10:Foster the establishment of BF support

groups and refer mothers to them
Summary :
Facility completely meets the Baby-friendly criteria
for Step 10

No

Achievements
Improvements required

Improvements recommended

Give emphasize to the mother regarding BF support

group.

Code compliance
Bil

item

Code 1

A review of records and receipts indicates that any

BMS, including special formulas and other feeding
supplies, are purchased by the health care facility for
the wholesale price or more

compliance

Yes

Code 2

The hospital complies with Code

Yes

Code 3

The hospital keeps infant formula cans and pre

prepared bottles of formula are kept out of view unless
in use

Yes

Code 4

Clinical staf able to give two reasons why it is

important not to give free formula samples from the
infant formula companies to mothers

Yes

Code compliance
Summary :
Facility completely meets the Baby-friendly criteria
for Code compliance
Achievements

Good

Improvements required

Not documentation

Improvements recommended

YES

Mother-friendly care
bil

item

compliance

MF1

Written policies require mother/baby friendly labour and

birthing practices and procedures:
-Birth companion
-allow drink and eat light food
-encourage for non drug method of pain relief
-encourage walk/move
-not involve invasive procedure

Yes

MF2

Clinical staf were able to describe at least 2

recommended practices and procedures that can help
mothers be more comfortable and in control during
labour and birth

62%

Mother-friendly care
bil

item

compliance

MF 3

Clinical staf can list at least 3 labour and birthing

procedures that should not be used routinely but only if
required due to complications

62%

MF4

Clinical staf are able to describe at least 2 labour and

birthing practices and procedures that make it more likely
that BF will get of to a good start

62%

MF5

Pregnant women were told by the staf that women could

have companions of their choice with them throughout
labour and birth and were given at least one reason it might
be helpful

Na

MF6

Pregnant women were able to describe at least 1

appropriate thing they were told by the staf about ways to
deal with pain and be more comfortable during labour and
what is better for mothers, babies and BF

Na

Mother-friendly care
Summary :
Facility completely meets the Baby-friendly criteria
for Mother-friendly care

No

Achievements

Not Meet the criteria

Improvements required

To emphasize the training to mother and stafs

Improvements recommended