University of Zambia Medical Library

Breastfeeding: A Training Course (WHO-DOCS 8)

In the past two decades, there has been a rapid increase in our understanding, not only of the scientific basis of lactation and suckling, but also of effective management and prevention of breast-feeding problems, including the use of basic counselling skills. Research has shown that if health workers’ attitudes and practices are supportive, it is more likely that mothers will breastfeed successfully and for a longer period.

Unfortunately, breastfeeding has been neglected in the training of most health workers, leaving a serious gap in both their knowledge and skills. Training is urgently needed at all levels in up-to-date and effective breastfeeding management. The CDD Programme in collaboration with UNICEF has developed the package "Breast-feeding counselling: A training course" to help to fill the gap.

The aims of the course:
The course aims at training a cadre of health workers in breastfeeding counselling. They will mostly be key workers, who can supervise breastfeeding management in a facility. Mothers who need help can be referred to them.

Target group:
The course was designed for health workers who care for mothers and young children in maternity facilities, hospitals and health centres. These include mid-wives, community nurses, paediatric nurses, and doctors, particularly those who are working at the first level of care. Obstetricians, paediatricians, and supervisory staff of programmes such as Control of Diarrhoeal Diseases and Acute Respiratory Infections, Immunization, Nutrition, and Family Planning will find the course useful as well, as it will help them to understand how they can support breastfeeding in their programmes.

Course structure: A course is normally for 15-20 participants and 5-6 trainers. The duration is 5 days or 40 hours in which 33 sessions are covered. The training is structured in a sequence of presentation, discussion, demonstration and exercise followed by clinical practice with real mothers and babies in a health facility. There are four clinical practice sessions of about two hours each.

When a course is introduced, an additional 40 hours, or 5 days are necessary for the preparation of trainers. This usually takes place in the week preceding the 5-day course for participants and is conducted by a director who has previous experience of conducting the course. Trainers go through the materials, become familiar with them, and learn how to teach the different kinds of sessions. They complete their training as trainers when they use the materials to teach the participants under the supervision of the director.

Content:
The main emphasis of the course is on the development of counselling and clinical skills to support optimal breast-feeding practices, and to help mothers overcome difficulties. Counselling skills include:

• Using helpful non-verbal communication.
• Asking open questions.
• Using responses and gestures that show interest.
• Reflecting back what the mother says.
• Empathizing – showing that they understand how a mother feels.
• Avoiding words which sound judging.

• Accepting what a mother thinks and feels.
• Recognizing and praising what a mother and baby are doing right.
• Giving practical help.
• Giving a little relevant information.
• Using simple language.
• Making one or two suggestions, not commands.

Clinical skills:
The clinical skills which are taught in the course are based on new scientific understanding of the suckling process. We now know that a baby’s early, correct attachment at the breast is important to establish breastfeeding and prevent problems. A baby needs to be well attached in order to suckle effectively and remove milk without damaging the nipple. Participants learn how to assess a breastfeed and look for these signs of good attachment:

• the baby’s chin is touching the breast.
• his mouth is wide open.
• his lower lip is turned outwards.
• more areola is visible above the baby’s mouth than below it.
• he takes slow, deep sucks, in burst with pauses.

• the baby's head and body should be straight.
• his face should face the breast, with his nose opposite the nipple.
• his mother should hold his body close to hers.
• if the baby is a newborn, she should support his whole body, and not just his head and shoulders.

How this course relates to other courses:
"Breastfeeding counselling: A training course" has been developed in collaboration with UNICEF. It provides a tool that fulfills the training requirements of the Baby Friendly Hospital Initiative (BFHI), as well as the needs in relation to breastfeeding of programmes concerned with child health. Other courses that are available are the UNICEF/WHO 18-hour course and the IBFAN/UNICEF 80-hour course. The main characteristics of the courses can be summarized as follows:

The UNICEF/WHO 18-hour course "Breast-feeding Management and Promotion in a Baby Friendly Hospital: an 18-hour course for maternity staff" is appropriate to inform health workers about maternity ward practices that support breastfeeding, and to introduce the Baby Friendly Hospital Initiative. Because it is short, the 18-hour course can be introduced quickly, but it does not give detailed training in clinical and counselling skills. It requires trainers who have experience in breastfeeding management and implementation of the BFHI.

The IBFAN/UNICEF document "Training Guide in Lactation Management" is a valuable resource for any trainer, but is usually used to prepare and teach an 80-hour course to develop a cadre of personnel with enough knowledge of lactation management to become trainers. Considerable experience is necessary to prepare and conduct such a course. These courses should be used to complement each other and to cater for the needs of different target groups and the various phases of an overall training plan. The materials are compatible, use similar terminology and make the same recommendations for optimal infant feeding practices and for the support and help that health workers can provide.

Implementing "Breastfeeding counselling: A training course":
The course was field tested three times, in 1991 in the Philippines, in 1992 in Jamaica and in 1993 in Bangladesh. After its completion, the training was introduced in Iran, and other countries have followed since. Experiences so far have been very encouraging. In countries where training on breastfeeding had already started before the course was introduced, for example the Philippines, Bangladesh and Iran, it has been observed that the materials filled a well recognised gap. Because they focus on the development of skills and provide built-in training of trainers, they can facilitate replication of much needed practical training. In several countries, plans are being developed in which the course is playing a central part in conjunction with other training on breastfeeding for different cadres.

The Programme for the Control of Diarrhoeal Diseases will be able to support the introduction of the 40-hour course in selected countries. A basic requirement for support is that a full course is conducted, which means that a director who has experience teaching the course prepares 5-6 trainers, who then train 15-20 participants under the supervision of the director. It is not recommended that only parts of the course be used or that fragments are fitted into other courses. Full benefit will only be obtained if the course is conducted in its original overall form, though allowing for some adaptation to local circumstances.

The Programme also considers it important that the course is introduced at a time when there is evidence that a country has the interest and capacity to continue and multiply the initial training. This usually means that there is a national coordinating body, such as a national breastfeeding committee that is responsible for planning and implementation of activities, and a full-time national breastfeeding coordinator. The course should fit into an overall breastfeeding training plan covering all cadres of health workers.

When a full 40-hour course plus preparation of trainers is planned and the above criteria are met, the Programme will be able to provide a complete set of materials including visual aids. Selectively, technical support from a CDD staff member or consultant to conduct the first course and to assist in planning future training activities, can be provided. Given the limited funds available to WHO, countries are encouraged to seek funds from other sources also. Collaboration with UNICEF and other agencies has been most fruitful on many occasions in this regard.

For further information, contact:
The Director, Division of Diarrhoeal and Acute Respiratory Disease Control, World Health Organization, 1211 Geneva 27, Switzerland, Tel: +41 22 791-2632, Fax: +41 22 791-4853, E-mail: tullochj@who.ch

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Last updated January 21, 1999