UNICEF UK Baby Friendly Initiative Stage 3 report Maternity Service
Bedford Hospital NHS Trust on 29-30 October 2014
UNICEF UK Baby Friendly Initiative 30a Great Sutton St, London, EC1V 0DU Tel: 0207 375 6052/6114 Fax: 0207 250 1733
[email protected] unicef.org.uk/babyfriendly
Contents Assessment result............................................................................................................................ 3 What mothers told us.................................................................................................................... 4 What is required before you can progress to full accreditation.......................................................... 5 How we recommend you achieve and maintain the standards ......................................................... 6 What happens next?......................................................................................................................... 8 The results in detail........................................................................................................................... 9 Background ................................................................................................................................... 9 The sample ................................................................................................................................... 9 Standard 1 – Antenatal care......................................................................................................... 10 Standard 2 – Care at birth ............................................................................................................ 10 Standard 3 – Getting breastfeeding off to a good start ................................................................ 10 Standard 4 – Informed decisions regarding the introduction of food or fluids other than breast milk ............................................................................................................................................. 11 Standard 5 – Close and loving relationships................................................................................. 11 Supporting information ................................................................................................................... 12 Achieving Sustainability .................................................................................................................. 12 Background information.................................................................................................................. 14 Appendix: About the Baby Friendly Initiative................................................................................... 15
Stage 3 report | Maternity Service | 29-30 October 2014 Bedford Hospital NHS Trust
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Assessment result What we found overall: We found that Bedford Hospital NHS Trust has met some but not all of the standards for Baby Friendly accreditation. Bedford Hospital NHS Trust has met the majority of the criteria relating to Stage 3 accreditation and the staff are highly commended for the efforts made. It was clear to the assessment team that in many areas pregnant women and new mothers receive a very high standard of care. The overriding impression gained by the assessment team is that there is a culture of kindness in the maternity unit, with most mothers specifically mentioning this in their feedback. In total, 85% of mothers stated that they were extremely happy with their care. A great deal of effort has gone into achieving the Baby Friendly standards and the team was impressed by the thorough approach to ensuring that all mothers receive a consistently good basic level of care. Also of note, is the efforts being made to improve breastfeeding rates at day 10 following research carried out at the unit. This work has included the re-introduction of a day 3 community midwife visit, a supplementation action plan and tongue tie service. The supplementation action plan has resulted in a reduction in supplements given to breastfed babies from 43% to 19% on the postnatal ward. The tongue tie service is carefully thought out, with a training package, guideline and formal assessment service for babies over 3 days old. The hospital works closely with the community services, including providing health visitors with the contact details of all pregnant women so that they can initiate antenatal care. They also work with local children’s centres that provide staff to support breastfeeding mothers in hospital and to signpost mothers to children centre services. Further detail is provided within this report to explain what criteria have not been full met and the Designation Committee are asked to consider what action is required before the facility can be accredited as Baby Friendly. Sue Ashmore 4 November 2014
In 2012 the Baby Friendly Initiative underwent a major review. This resulted in revised standards which will now be incorporated into all assessments gradually between 2014 and 2016 (see the transition guidance for more detail). The above result relates to the original Baby Friendly standards. The facility is advised to continue work to ensure that the new standards are incorporated into training and practice prior to the reassessment. Stage 3 report | Maternity Service | 29-30 October 2014 Bedford Hospital NHS Trust
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What mothers told us All mothers interviewed were asked to rate their overall satisfaction with the maternity service and given a chance to feedback further comments. The results are presented below:
Overall care from maternity service
% of mothers
Very happy with care – no complaints or comments
85%
Fairly happy or neutral
15%
Unhappy with care overall
0%
“The care at this hospital far exceeded my expectations. It was fantastic compared to the care I received with my last baby”
“The care enabled me to continue feeding my baby through his illness, it meant so much”
“The staff are really kind and nothing is too much trouble. I just wish they would tell each other what is going on, I kept having to tell my story again and again”
Stage 3 report | Maternity Service | 29-30 October 2014 Bedford Hospital NHS Trust
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What is required before you can progress to full accreditation Actions that are required are mandatory if the criteria for Stage 3 are to be met and the facility able to progress to full accreditation. If any requirements are made, these are listed below. The Designation Committee will be asked to consider what additional evidence is required. This may take the form of written evidence or a follow-up assessment that will usually happen within 6 months. Further requirements may be made in the future in relation to any changes made, and in light of practice found or current research evidence. 1. An improvement in the number of pregnant women reporting that they had a discussion about feeding their baby is required.
Stage 3 report | Maternity Service | 29-30 October 2014 Bedford Hospital NHS Trust
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How we recommend you achieve and maintain the standards Recommended actions are those that have proven valuable in other units in helping them to
achieve and maintain the requirements. In some cases implementation (or not) of these recommendations is likely to make a significant difference to practice and thus to the ability of the facility to achieve and subsequently maintain the Baby Friendly standards. The recommendations made by the assessment team are listed in this report. Further recommendations may be made in the future in relation to any changes made, and in light of practice found or current research evidence. 1. Standard 1 – Antenatal information The majority of pregnant women reported having some discussion around feeding their baby. However, a few stated that this was only being asked their feeding intention and so they had not found the discussion helpful. The unit uses the national handheld records which are currently being updated to include the new Baby Friendly standards. We recommend that staff receive further update training using the new Baby Friendly conversation guidance to support them to have meaningful discussions with women and to complete the new records. 2. Standard 2 – Care at birth (breastfeeding mothers) Whilst most mothers reported having skin contact for at least one hour after birth, it was notable that many reported this being interrupted for routine care and then re-instated later on. Few mothers reported very long uninterrupted skin contact from birth leading to a first breastfeed. We recommend that work continues to keep improving the care around this standard. 3. Standard 2 – Care at birth (formula feeding mothers) Very few of the mothers interviewed gave a formula feed as the first feed and so it was not possible to assess this standard. Vigilance is recommended to ensure that bottle feeding mothers are encouraged to give the first feed in skin contact. 4. Standard 3 – Breastfeeding assessments A great deal of work has gone into ensuring that all mothers have formal breastfeeding assessments carried out and 86% of breastfeeding mothers reported that this had happened. While this is excellent, vigilance is recommended that this recent improvement in care continues and improves. 5. Standard 4 – Maximising breastmilk A great deal of work has been undertaken to reduce the number of supplements given to breastfed babies. As part of this work, a policy of expressing breastmilk and feeding this to babies who do not feed on delivery suite has been adopted. Further expressing and feeding is advised at 6 and 9 hours if the baby remains reluctant to feed. While it is acknowledged that this practice has reduced supplementation with formula milk, it could also help create Stage 3 report | Maternity Service | 29-30 October 2014 Bedford Hospital NHS Trust
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an impression among staff and parents that healthy term babies are at risk if they are not fed very regularly in the first hours after birth. In the longer term it could also have the opposite effect to that intended by encouraging the use of formula milk when expressed breastmilk is not available. We recommend that efforts to continue to improve the length and quality of skin contact be implemented (including using laidback nursing) and babies given time and patience to feed. Continued rigorous auditing of this standard is also recommended.
Paperwork and processes Work to implement Baby Friendly standards has so far concentrated on achievement of the original standards. Building on the achievement to date, work is now needed to ensure that the content and ethos of the revised standards is fully reflected in all policies, training curricula and mechanisms for providing care prior to reassessment. Further information is available online about developing a policy and supporting curriculum development. We recommend that the draft hypoglycaemia policy and flowcharts be amended to reflect the current reluctant feeder guideline and hypoglycaemia policy.
Stage 3 report | Maternity Service | 29-30 October 2014 Bedford Hospital NHS Trust
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What happens next?
The Designation Committee will consider the outcome and you will be informed by letter of what is required.
Stage 3 report | Maternity Service | 29-30 October 2014 Bedford Hospital NHS Trust
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The results in detail Background The revised Baby Friendly standards incorporate many of the previous standards and also include some brand new standards that have no current equivalent. It is recognised that it will take facilities a number of years to fully incorporate the new standards into practice and therefore UNICEF UK is using a phased approach to what is expected at assessment (see the transition guidance for more detail). The table below lists all the revised standards with brand new standards shaded and those with an equivalent in the previous standards not shaded. It is expected that facilities will achieve the required standard for the previous (unshaded) standards in order to achieve a ‘pass’. The brand new (shaded) standards have been assessed and the result given for guidance only. Where a split result is given (e.g 100%/0%) the first number relates to the equivalent previous standard and the other number to the result for the full new standard.
The sample All mothers were randomly selected for interview. Number of mothers interviewed: Breastfeeding Formula feeding With a baby on the neonatal unit
Stage 3 report | Maternity Service | 29-30 October 2014 Bedford Hospital NHS Trust
45 32 7 6
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Standard 1 – Antenatal care
Criterion - Mothers who confirmed that… They had the opportunity for a discussion about feeding their baby They had the opportunity for a discussion about the importance of developing a relationship with their unborn baby and that the conversation met their needs
Result
Standard required
74% 80% 35%
Standard 2 – Care at birth
Criterion - Mothers who confirmed that…
Result
Standard required
Care at birth (breastfeeding mothers)
They were able to have skin contact for at least one hour and support to offer the first feed in skin contact
97%
80%
Care at birth (formula feeding mothers)
They were able to have skin contact for at least one hour and support to offer the first feed in skin contact
-
80%
Skin contact on the neonatal unit
They had been able to hold their baby in skin to skin contact
100%
80%
Result
Standard required
Standard 3 – Getting breastfeeding off to a good start
Criterion - Mothers who confirmed that… Positioning and attachment
They were supported with learning how to position and attach their baby
93%
80%
Hand expression
That staff offered to show them how to hand express
93%
80%
They understood baby led feeding and how to recognise feeding cues
100%
They understood responsive feeding
28%
Responsive feeding
Stage 3 report | Maternity Service | 29-30 October 2014 Bedford Hospital NHS Trust
80%
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Recognising effective feeding
They were aware of how to recognise effective feeding
100%
80%
Ongoing support information
They were aware of support available and how to access this
93%
80%
Breastfeeding assessments
Breastfeeding assessments were carried out
86%
80%
Initiating expressing for mothers with a baby on the neonatal unit
They had been encouraged to express as soon as possible after the birth
100%
80%
They received effective support to express
100%
80%
Standard 4 – Informed decisions regarding the introduction of food or fluids other than breast milk
Result
Standard required
Their baby had received a supplement Informed maternal decision or clinical indication
1
N/A
Their baby had received a supplement Not informed maternal decision or clinical indication
0
0
Criterion - Mothers who confirmed that…
Maximising breastmilk
Formula feeding mothers
They had been supported with learning about making up feeds
85%
Responsive bottle feeding
57%
80%
Standard 5 – Close and loving relationships
Criterion - Mothers who confirmed that… They had received information about the importance of close and loving relationships
Stage 3 report | Maternity Service | 29-30 October 2014 Bedford Hospital NHS Trust
Result
Standard required
55%
80%
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Supporting information Criteria
Result
Standard required
No advertising
No advertising
Partial
Meets standards
Written and other information
Meets standards
Meets standards
Mechanisms
Meets standards
Meets standards
Observations within the facility Policies and guidelines
Achieving Sustainability The aim of UNICEF UK is for the Baby Friendly Initiative standards to become routine practice that does not require continued external assessments to be maintained. The criteria listed below are considered necessary to achieve sustainable change. At Stage 2 and 3 assessments these criteria are assessed to provide guidance only. From July 2016 the criteria marked* will be required to be met at all re-assessments of accredited facilities. Areas
Criteria
Leadership Senior Management
Reporting mechanisms up to own managers. Reporting mechanisms from line reports*. Financial security Understanding of process
Line Management
Reporting mechanisms up to own managers. Supervision of project lead Reporting mechanisms from staff* Support for staff education* Supervisory mechanisms*
Project lead
Hours Sustainability of post* Responsibilities Education
Project support
Adequate to needs of facility Clearly defined purpose Structured
Stage 3 report | Maternity Service | 29-30 October 2014 Bedford Hospital NHS Trust
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Areas
Criteria
Audit and evaluation
Audit
Outcome data
Breastfeeding rates including: o Coverage at least *% o Reporting process that allows for monitoring of the breastfeeding rates over time* The following are monitored: Re-admissions Supplement rates Patient surveys Other
Evaluation
Frequency and areas covered allow for adequate monitoring* Effective training of auditors Thorough dissemination of results System to improve weak results*
Analysis of audit and outcome data* Action planning Reporting
Collaborative working
Standard
Excellent
Basic communication between midwifery - neonatal unit, health visiting-children’s centres including sharing audit and evaluation data* Communication between midwifery / neonatal and health visiting to support individual mothers to have consistent care* System to support joint working across sectors Safe data sharing to allow pregnant and new mothers to be contacted Joint planning Resource sharing Joint evaluation
Comments: 1. The managers interviewed expressed a strong commitment to the Baby Friendly process as a way of improving the care provided on the unit. The management team work closely together and there is an emphasis placed on staff recognition and wellbeing as an important element of ensuring high standards of care. The audit and evaluation processes across all areas are thorough and the results considered carefully with action taken when required. The unit has good working relationships with the community services resulting in collaborative endeavour to improve care. 2. The Band 7 infant feeding lead will soon be moving post to be head of quality assurance. We strongly recommend that the infant feeding strategic lead post be continued to ensure that the standards are maintained and improved.
Stage 3 report | Maternity Service | 29-30 October 2014 Bedford Hospital NHS Trust
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Background information Breastfeeding statistics The most recent infant feeding statistics provided by the facility are as follows: Feeding category Age/stage collected
Full / total breastfeeding
Initiation
80%
10 day
45%
Partial breastfeeding
Artificial feeding
Unknown
15%
40%
-
These statistics relate to 90% of the population served by the facility.
Progress with Baby Friendly accreditation
Stage 2 accreditation awarded May 2013. Stage 1 accreditation awarded May 2011.
Births per year
3015
Facilities
Antenatal clinic, delivery suite, postnatal ward, transitional care and Level 1 neonatal unit with 12 cots.
Local demographics
Mixed population with some urban and rural areas and some ethnic minorities.
Infant feeding lead hours
30 hours at Band 7
Any additional support for the infant feeding lead
20 hours at Band 6 15 hours at Band 3
Classroom training (hours provided)
16 hours
Practical skills review (hours provided)
1 hour.
Training for medical staff (hours provided)
1 hour by the infant feeding lead as part of induction
Stage 3 report | Maternity Service | 29-30 October 2014 Bedford Hospital NHS Trust
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Appendix: About the Baby Friendly Initiative The Baby Friendly Initiative is a worldwide programme of the World Health Organization and UNICEF. It was established in 1992 to encourage maternity hospitals to implement the Ten Steps to Successful Breastfeeding and to practise in accordance with the International Code of Marketing of Breastmilk Substitutes. The UNICEF UK Baby Friendly Initiative subsequently extended the principles to include community health-care services and university programmes for midwifery and health visiting/public health nursing. In 2012, following a comprehensive review, the Baby Friendly standards were updated to include parent infant relationship building and very early child development, plus enhanced requirements in communication skills for staff. The new standards are being gradually introduced into all assessments, with full compliance expected by July 2016. Initial accreditation as a Baby Friendly facility takes place in three stages: Stage 1 of the assessment procedure is designed to ensure that the necessary policies, guidelines, information and mechanisms are in place to allow health care providers to implement the Baby Friendly standards effectively. Stage 2 involves the assessment of staff knowledge and skills. Stage 3 assesses the implementation of the Baby Friendly standards in the care of pregnant women and new mothers. Re-assessment takes place after two years with the aim of ensuring that the standards are maintained. Ongoing assessment is carried out every three-five years with the same goal of ensuring the maintenance of standards. The work of the Baby Friendly Initiative within the UK is overseen by the Designation Committee, a panel of impartial experts in the field of breastfeeding and neonatal care including representatives from paediatrics, midwifery and health visiting, voluntary organisations and mother support groups as well as representatives from Baby Friendly accredited facilities. The findings from all assessments are reviewed by the Designation Committee in order to ensure consistency and fairness.
Register of intent (move to Certificate within 1 year)
Certificate of Commitment (move to Stage 1 within 1 year)
Stage 1 assessment (move to stage 2 within 2 years)
Stage 3 report | Maternity Service | 29-30 October 2014 Bedford Hospital NHS Trust
Stage 2 assessment (move to stage 3 within 1 year)
Full accreditation (re-assessment after 2 years)
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