The Sharjah Baby-Friendly Campaign: A Community-Based Model for Breastfeeding Promotion,Protection,and Support

Abstract

Introduction:

Breastfeeding promotion, protection, and support are one of the most cost-effective public health interventions to advance maternal and child health. The World Health Organization, the United Nations International Children's Emergency Fund, and numerous health organizations have recommended exclusive breastfeeding for the first 6 months of life, which is a key indicator of breastfeeding promotion programs worldwide. Despite the recommendations and various initiatives to promote breastfeeding, most women do not reach the exclusive breastfeeding target in both developed and developing countries. Such has been the case in the United Arab Emirates (UAE).

Materials and Methods:

Therefore, based on the decree for breastfeeding promotion, protection, and support by the ruler of the Emirate of Sharjah, UAE, H.H. Sheikh Doctor Sultan Al Qasimi, a multisectorial, multidirectional breastfeeding campaign—the Sharjah Baby-Friendly Campaign—was launched in March 2012 by H.E. Sheikha Bodour Al Qasimi, under her patronage. It consisted of four initiatives—namely, Baby-Friendly Health Facility, Mother-Friendly Workplace, Breastfeeding-Friendly Nursery, and Mother-Baby Friendly Public Place. Once an organization met the criteria for any of these initiatives, it was awarded the designation or accreditation of that initiative.

Results:

The campaign initiatives worked through capacity building of healthcare workers, provided professional support and facilitation for the accreditation process, developed breastfeeding education content and resources, and organized and conducted breastfeeding promotion seminars in health facilities and community, as well as community outreach through social media and an innovative mobile mother' room.

Conclusions:

The positive impact of the campaign on breastfeeding promotion, protection, and support is evident by the increased exclusive breastfeeding rate at 6 months and decreased bottle feeding rates at both 4 and 6 months.

Introduction

Breastfeeding promotion, protection, and support are one of the most cost-effective public health interventions to advance maternal and child health. Exclusive breastfeeding for the first 6 months of life is recommended by the World Health Organization (WHO) and is a key indicator of breastfeeding promotion programs worldwide. However, most women fail to reach the recommended exclusive breastfeeding target in both developed and developing countries.^1,2 Nonetheless, various policy initiatives, including the International Code of Marketing of Breastmilk Substitutes (1981), the Innocenti Declaration (1990), the Baby-Friendly Hospital Initiative (BFHI) (1991), and most recently the Global Strategy for Infant and Young Child Feeding (2002) have been developed to tackle this public health issue. In spite of all of these programs, the United Nations International Children's Emergency Fund (UNICEF) global databases for 2015 reports that only 38% of children under 6 months of age are exclusively breastfed.³ Worldwide, there are hundreds of interventions based on a single-strategy approach to promote breastfeeding, for instance, within the healthcare system, mother-to-mother support, laws protecting breastfeeding, etc., that have been implemented with variable success. However, evidence-based frameworks and models to promote the effective scale-up and sustainability of breastfeeding programs are still lacking.^2,4–9

Breastfeeding in the Emirate of Sharjah, United Arab Emirates

Sharjah is one of the seven Emirates of the United Arab Emirates (UAE). It stretches from the Arabian Gulf to the Gulf of Oman. Its population is 846,000, of whom 85% live in the city of Sharjah.¹⁰ There were 11,969 live births in 2014 in the Emirate of Sharjah, UAE, and 50% of these births were in government hospitals (unpublished data from the Ministry of Health [MOH], UAE). In 1992, under a directive from the MOH, the Emirate of Sharjah began a comprehensive program of breastfeeding support, through both laypersons and health professionals; yet, exclusive breastfeeding at 6 months was reported to be only 13.3% in 2006¹¹ and 18.1% in 2011 (unpublished data for 2011 from the Sharjah Baby-Friendly Campaign [SBFC] preliminary survey on breastfeeding).

In 2010, based on an invitation from the Supreme Council of Family Affairs of Sharjah, an innovative public health campaign for breastfeeding promotion was presented to the Royal Family of Sharjah. A decree supporting it was signed by H.H. Sheikh Doctor Sultan Al Qasimi and issued on February 8, 2011, and on March 1, 2012, H.E. Sheikha Bodour bint Sultan Al Qasimi launched the SBFC, under her patronage.

The vision of SBFC was to create a breastfeeding culture where breastfeeding would be valued, protected, and considered as normal, not only within healthcare facilities but also in workplaces, daycare centers and nurseries, and public places. The focus of the campaign was to address the barriers and obstacles encountered by mothers after hospital discharge. The underlying principle of the campaign was that it had to be multisectorial, multidirectional, and not limited to the health sector but extended to the community, both at an institutional and at the grass roots level.

The three community-based initiatives of SBFC were founded on the integrative process of social mobilization, where community members are motivated to become active participants in driving a social change for a common goal using diverse strategies. The concept of community ownership of breastfeeding promotion and support was promoted and sustained, clearly delineating that the campaign was not the sole responsibility of the health professionals and healthcare facilities (Fig. 1).

FIG. 1.

Sharjah Baby-Friendly Campaign community-based model of breastfeeding promotion, support, and protection based on the concept of community and social mobilization.

The SBFC is composed of four complementary initiatives:

I. Baby-Friendly Health Facility. The Baby-Friendly Health Facility Initiative by the SBFC was based on an internationally accredited program launched by WHO and UNICEF in 1991. It aimed to create a healthcare environment that supported breastfeeding as the norm. The UAE MOH (Maternal and Child Health Central Administration) has promoted the BFHI since 1993, and 11 health facilities have received BFHI accreditation up to 2011.

Since its launch in 2012, SBFC has been facilitating BFHI implementation and assessment for 22 MOH primary health centers, four MOH hospitals, and three private hospitals in the Emirate of Sharjah. In order to be Baby-Friendly the health facility has to establish the policy covering the BFHI 10 Steps for a hospital or the 7 Points for a health center,¹² comply with the International Code of Marketing of Breastmilk Substitutes, and train the healthcare staff in skills necessary to implement the policy.

The 7 Points for the health centers included:

i. Have a written breastfeeding policy that is routinely communicated to all healthcare staff.

ii. Train all healthcare staff involved in the care of mothers and babies in the skills necessary to implement the policy.

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

iv. Support mothers to initiate and maintain breastfeeding.

v. Encourage exclusive and continued breastfeeding, with appropriately timed introduction of complementary foods.

vi. Provide a welcoming atmosphere for breastfeeding families.

vii. Promote cooperation among healthcare staff, breastfeeding support groups, and the local community.

The Baby-Friendly accreditation was a staged process that included registration of intent, implementation workshop/field visits, awarding certificate of commitment, internal assessment by the SBFC team, external assessment by MOH assessors, and then final accreditation.

II. Mother-Friendly Workplace. The Mother-Friendly Workplace initiative by the SBFC supports the return of breastfeeding mothers so that they can continue with breastfeeding. The designation is awarded to organizations having a written breastfeeding policy for their employees, a designated facility and approved work break time to allow breastfeeding or expression while at work, and on-site peer support.

III. Breastfeeding-Friendly Nursery. This initiative provides information and support to mothers on maintaining their milk supply and continuing breastfeeding. The designation is awarded to daycares and nurseries that have a breastfeeding policy, a room for the mothers to breastfeed their baby or to express their milk (before leaving their baby), staff trained in breastfeeding support, and literature and visuals portraying breastfeeding as the norm.

IV. Mother-Baby Friendly Public Place. This initiative supports breastfeeding mother and baby in public places like malls, parks, museums, etc. The designation is awarded to any public place that has a written breastfeeding policy and provides a room—clearly indicated within the premises—for clients to breastfeed in comfort and privacy.

The SBFC team did the final assessment for the other three initiatives—that is, Mother-Friendly Workplace, Breastfeeding-Friendly Nursery, and Mother-Baby Friendly Public Place—and the respective designation was awarded once all the criteria were met.

The following strategies were incorporated in the implementation of SBFC's four initiatives:

1. Capacity building of healthcare workers to promote and support breastfeeding. The SBFC conducted 10 different seminars and workshops from 2012 to 2015 (Table 1). In total, 1,400 health professionals were trained, and 25,844 continuing medical education hours were awarded. These courses and trainings were provided free of charge. The clinical practice for the 20-hour BFHI course by WHO/UNICEF, as well as the clinical attachment for lactation management training, were conducted at the Lactation Clinic at the Maternal and Child Health Center in Sharjah. It is the first and only community-based health facility in the UAE that has been awarded the “2015 IBCLC Community Care Award” from the U.S. International Board of Lactation Consultant Examiners and the U.S. International Lactation Consultant Association.

2. Professional support. This consisted of two components. First, we developed guidelines and educational tools and resources, and second, we had regular meetings and made frequent field visits. The Campaign's team conducted up to 700 meetings and visits to public and private bodies and facilities in Sharjah from 2012 to 2015 to familiarize different stakeholders with the Campaign's objectives and missions. In addition, an extensive lactation management program was carried out. Furthermore, a proposal of a sustainable workforce development including medical, nursing, and health sciences schools was developed.

3. Antenatal education classes. Antenatal education classes were launched by the SBFC with evidence-based educational materials and DVDs. According to the BFHI criteria, 80% of the mothers attending antenatal clinics should receive education on breastfeeding, which is being met by the MOH health facilities, whereas the private health facilities are working toward it in the Emirate of Sharjah.

4. Back to work education classes. These classes were introduced by the SBFC for Mother-Friendly workplaces, which included training of focal points at these institutions to provide on-site mother-to-mother support. This is an ongoing activity of the Mother-Friendly Workplace Initiative.

5. Well baby infant and young child feeding classes. These classes were launched for the first time in the region by the SBFC in which infant and young child feeding education is given in four different parts to the mothers bringing their children for vaccination at the health centers; each part is given at separate visits. The mother is educated on the nutritional needs and requirements for the specific age bracket of her child.

6. Distribution of a breastfeeding educational DVD. The SBFC acquired copyrights to a breastfeeding education DVD produced by the Best Beginnings charity from the United Kingdom, titled “From Bump to Breastfeeding.” SBFC titled it “From Pregnancy to Breastfeeding” in Arabic. These DVDs were distributed to all UAE hospitals as well as during events and exhibitions.

7. Development of SBFC Web site and social media accounts. The SBFC developed a Web site (which can be accessed at www.sharjahbabyfriendly.ae) and became very active in social media through twitter (@sharjahbabyfriendly), Instagram (@shjbabyfriendly), Facebook (sharjahbabyfriendlycity), and a blog in order to reach a diverse group of stakeholders.

8. SBFC Android™ (Google, Mountain View, CA) and iOS (Apple, Cupertino, CA) applications. SBFC developed and launched Android and iOS applications for smartphones to engage community members from all age groups, especially the younger generation, in the breastfeeding promotion, which can be downloaded at http://appstore.com/sharjahbabyfriendlycampaign in Arabic. The English language version will be added in the near future.

9. Mobile Mother Room. An innovative idea suggested by H.E. Sheikha Bodour Al Qasimi, the daughter of the ruler of Emirate of Sharjah, H.H. Sheikh Sultan Al Qasimi. The Mobile Mother Room is a caravan stationed at public places having fairs, exhibitions, and festivities and wherever an on-site mother's room is not available. It provides a relaxed and private environment equipped with comfortable seating, a baby changing area, and a breastmilk pumping facility. Therefore mothers can comfortably breastfeed their babies and pump breastmilk as needed (Figs. 2 and 3).

10. Community-based breastfeeding promotion and support for breastfeeding mothers. The SBFC encourages mother-to-mother support groups in the four initiatives and across all the districts of Sharjah. Training and awareness sessions were also provided to more than 1,000 laypersons in the community. Furthermore, visibility community events (for example, World Breastfeeding Week) are celebrated with annual communications and mass media campaigns.

11. Breastfeeding support hotline as part of community-based initiatives. A breastfeeding support hotline has been available (12 hours a day, 7 days a week) in Sharjah, managed by a community support group for breastfeeding mothers. However, since the operation of SBFC, a separate breastfeeding support hotline has been available for other cities in the Emirate of Sharjah. Moreover, a few health centers in the remote area formed a Whatsapp group for breastfeeding community support to reach out to the mothers in their vicinity.

FIG. 2.

Mobile Mother Room launched by the Sharjah Baby-Friendly Campaign in 2013.

FIG. 3.

Interior of the Sharjah Baby-Friendly Campaign Mobile Mother Room.

Table 1.

Courses, Seminars, and Trainings Conducted by the Sharjah Baby-Friendly Campaign

1. 20-hour BFHI course by WHO-UNICEF (in English and Arabic)

2. 90-hour Advanced Lactation seminar

3. Clinical attachment for lactation management training

4. Training of Trainers course for Infant & Young Child Feeding Counseling

5. Infant & Young Child Feeding counseling course

6. Tongue-Tie seminar

7. Workshop for Breastfeeding Antenatal & Postnatal Education

8. Workshop Training the Trainer “Orientation for Non-Clinical Staff”

9. Breastfeeding Intermediate Clinical Practice for Nurses & Doctors

10. WHO/UNICEF BFHI Assessor Training Program

BFHI, Baby-Friendly Hospital Initiative; UNICEF, United Nationas International Children's Emergency Fund; WHO, World Health Organization.

What Has SBFC Achieved?

There is evidence from the two studies conducted by the SBFC—a preliminary study on breastfeeding in 2011(unpublished data) and a knowledge attitude and practice survey on breastfeeding in 2013 (preliminary results; unpublished data)—suggesting positive findings regarding breastfeeding. Within 2 years of the launch of SBFC, the exclusive breastfeeding rate for the first 6 months increased from 18.10% in 2011 to 39.9% in 2013, the formula feeding rate at 4 months decreased from 27% in 2011 to 24% in 2013, and the formula feeding rate at 6 months decreased massively from 67% in 2011 to 35.9% in 2013 (Table 2).

Table 2.

Breastfeeding and the Sharjah Baby-Friendly Campaign

	Change in indicators
SBFC indicator	Before the campaign (up to 2011)	After the launch of the campaign	In progress
1a. Baby-Friendly health facility: BFHI accreditation (government health facility)	2	12^a	14^b (Total 26^c)
1b. Baby-Friendly health facility: BFHI accreditation (private health facility)	0	None	3 (Total 5^c)
2. Mother-Friendly workplace designation	0	70^a	12^b (Total 82^c)
3. Breastfeeding Friendly nursery designation	0	27^a	Total 27^c
4. Mother-Baby Friendly public place designation	0	15^a	2^b (Total 17^c)
5. Number of healthcare staff trained regarding breastfeeding support, promotion, and management	50	1,400^a	Not applicable
6. Number of continuing medical education hours awarded	1,000	25,886^a	Not applicable
7. Exclusive breastfeeding rate in MOH hospitals at discharge	70%	95%^d	Not applicable
8. Rate of birth at accredited Baby-Friendly hospitals in Sharjah	34%	77%^d	Not applicable
9. Rate of exclusive breastfeeding for the first 6 months of infant's age	18.1%^e	39.86%^f	Not applicable
10. Rate of formula feeding at 4 months of infant's age	27%^e	24%^f	Not applicable
11. Rate of formula feeding at 6 months of infant's age	67%^e	35.9%^f	Not applicable

As of October 2015.

Estimated achievement by December 2015.

Total numbers.

Based on 2014 hospital data.

According to Sharjah Baby-Friendly Campaign preliminary survey in 2011 (unpublished data).

According to Sharjah Baby-Friendly Campaign knowledge attitude and practice survey on breastfeeding in 2013 (preliminary results; unpublished data).

BFHI, Baby-Friendly Hospital Initiative; MOH, Ministry of Health.

These improvements reflect the success of SBFC in developing an all-encompassing breastfeeding culture based on innovative, multispectrum, and multidirectional strategies that involve all strata of the community. With 124 organizations being accredited under the four SBFC initiatives, Sharjah is preparing to celebrate its achievements as the first Baby-Friendly City in the region.

Footnotes

Acknowledgments

The SBFC team is indebted to all those who contributed in any way in this endeavor. We would like to acknowledge H.E. Sheikha Bodour bint Sultan Al Qasimi for her encouragement and support that makes our dream come true and the mission to be successful.

Disclosure Statement

No competing financial interests exist.

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