The Readiness for Implementing a Baby-Friendly Hospital Initiative at PKU Muhammadiyah Gombong Hospital

Breastfeeding practices for newborns require adequate support from the hospital, including its staff and policies. This concept can be implemented through a baby-friendly hospital initiative. This study aimed to identify the readiness for implementing a baby-friendly hospital initiative at PKU Muhammadiyah Gombong Hospital. A descriptive study was conducted among hospital staff in charge of newborn care as many as 85 people recruited using total sampling, and 101 postpartum mothers recruited using purposive sampling. The readiness for implementing a baby-friendly hospital initiative was examined through the knowledge and perceptions of the hospital staff and the practice of implementing the baby-friendly hospital, which were measured using questionnaires. A descriptive data analysis was carried out using STATA Version 16. The results showed that the majority of hospital staff had good knowledge and perceptions of the baby-friendly hospital initiative (97.65% and 74.12%, respectively). Seven of the 10 steps for successful breastfeeding had been implemented in the hospital, while the other three steps, i.e., skin-to-skin contact, immediate breastfeeding one hour after birth, and health workers ’ recommendation of breastfeeding support to mothers, had not been carried out. It is concluded that

Exclusive breastfeeding provides short and long-term benefits for both mothers and babies. However, its practices have not been optimally implemented in Indonesia and worldwide. Based on Indonesia's health profile data in 2019, the percentage of newborns receiving early initiation of breastfeeding was 75.58%, and infants receiving exclusive breastfeeding was 67.74%. Furthermore, infants who received early initiation of breastfeeding in Central Java were 83.63%, while those who received exclusive breastfeeding were 69.76% (Kementrian Kesehatan Republik Indonesia, 2019). Based on these data, there are babies who do not receive early initiation of breastfeeding and exclusive breastfeeding. Early breastfeeding initiation is an important determinant of the success of breastfeeding for infants.
The low rate of immediate breastfeeding in hospitals in Indonesia may be affected by several factors, including the quality and quantity of health education about breastfeeding, marketing and effects of formula milk companies, hospital infrastructures, policies, legislation, and procedures, as well as perceptions of the need for formula milk. For example, a previous study reported that respondents and health staff received inadequate or incorrect health education about breastfeeding, producers promoted the use of formula milk inside and outside the hospital, constraints on facilities and infrastructures that did not support early initiation of breastfeeding, inconsistent implementation of policies and procedures that support breastfeeding, and the belief of health staff and respondents that formula milk is necessary to improve infant health (Flaherman et al., 2018).
Mothers who gave birth by caesarean section tend to be slower in initiating early breastfeeding and have a lower prevalence of practicing exclusive breastfeeding when compared to those who gave birth vaginally. Research shows that 12 (44%) mothers of the post-caesarean section had produced breast milk on the first day after the surgery, but only 3 (11.11%) gave breast milk to their babies on that day. Out of 27 mothers giving birth by caesarean section, 5 (18.5%) mothers were not staying in the same room (roomin) with their babies on the first day. Health workers would send the babies to their mothers for breastfeeding if the mothers had farted and the urinary catheter had been removed. The health workers' support and rooming-in are needed for early breastfeeding practices in postpartum mothers with caesarean section (Dewi, 2016).
Early breastfeeding initiation is rarely applied in caesarean delivery due to pain of surgical wounds, anesthetic effects, maternal discomfort, and unproduced breast milk after surgery. Mothers who give birth by caesarean section are not able to breastfeed independently. They need assistance from health workers to provide breast milk to the baby immediately after birth. Nursing care before surgery, such as counseling on how to relax and implement early initiation of breastfeeding among post-caesarean section mothers, is necessary. Counseling will create motivation for mothers to provide immediate breastfeeding and breastfeed well. The comfort factor significantly influences an early breastfeeding initiation among mothers with post caesarean section. Nursing interventions to deal with this comfort are needed to support the breastfeeding process immediately after birth, including relaxation, distraction, and mentoring. The husband's presence during immediate breastfeeding also influences mothers to reduce discomfort. If the comfort problem is resolved, the mother will be able to provide immediate breastfeeding appropriately.
WHO supports the practice of exclusive breastfeeding in health services by providing the Baby-Friendly Hospital Initiative (BFHI) guidelines, one of which contains 10 steps for successful breastfeeding. The BFHI in Indonesia is known as Rumah Sakit Sayang Bayi. The implementation of the BFHI program has shown a positive impact on the breastfeeding process, namely duration, supporting mothers to breastfeed on demand, and practicing breastfeeding while the baby is hospitalized (Zhang et al., 2020). Health workers and hospital staff believe that BHFI is beneficial as it improves patient care, nurse knowledge, and patient health. However, changes to the activities when implementing BFHI are challenging for nurses. Nurses stated that various psychological, practical, and logistical factors were barriers to the implementation of BFHI. The main psychological problem is that nurses have to change their habits at work. Financing also becomes a challenge since the hospitals should provide more funding for the implementation of BFHI. Collaboration with other healthcare teams is another obstacle in implementing BFHI. For example, nurses should collaborate with the anesthesia team to practice skin-to-skin contact in the operating room for mothers who give birth by caesarean section. Other barriers to the implementation of BHFI include negative attitudes of patients and health workers, misinformation, and lack of communication between departments in hospitals.
The benefits of implementing a baby-friendly hospital have been reported in previous studies. However, not all hospitals in Indonesia have implemented this concept. Therefore, it is necessary to identify the readiness of PKU Muhammadiyah Gombong Hospital to implement a babyfriendly hospital. Therefore, this study aimed to identify the readiness for implementing a baby-friendly hospital at PKU Muhammadiyah Gombong Hospital.

METHODS
This study employed a descriptive research design with a quantitative approach and was conducted at PKU Muhammadiyah Gombong Hospital from November to December 2021. The samples were the hospital leaders, hospital staff, and postpartum mothers. The hospital staff consisted of nurses, midwives, general practitioners, specialist doctors, pharmacists, and administrative personnel who potentially interacted with breastfeeding patients and their families, with a total of 85. Meanwhile, the patient respondents were postpartum mothers (n=101) who gave birth at the hospital and were recruited using a consecutive sampling technique. The research variables in this study were the hospital staff's knowledge and perceptions of the baby-friendly hospital and the implementation of the babyfriendly hospital initiative that were derived from patients. The hospital staff's knowledge and perceptions of the babyfriendly hospital were measured using a questionnaire from a study by Pound et al., (2016). The questionnaire for measuring the implementation of the baby-friendly hospital based on the application of 10 steps of successful breastfeeding was adopted from Zhang et al. (2020). The questionnaires had gone through cross-cultural adaptation, which consisted of several steps, i.e., (1) requesting permission to use the questionnaire, (2) translating the questionnaires from English into Indonesian by two English and Indonesian language experts in the field of nursing, (3) back-translating the questionnaires from Indonesian into English by two English language experts who were not health professionals, (4) discussing the English and Indonesian versions of the questionnaire with a pediatrician who is a breastfeeding counselor, nurse, and English-Indonesian expert translator, and (5) testing the questionnaires to 20 hospital staff and postpartum mothers to determine their understanding of the statements in the questionnaires. Data analysis was performed using STATA version 16. Table 1 shows that most hospital staff whose duties were related to caring for breastfeeding mothers and their families were midwives (36.5%), working in the delivery room (20.1%), women (74%), Diploma III graduates (63.5%), aged 31-40 (48.2%), had work experience of 1-5 years (37.6%) and had never received training on the baby-friendly hospital (69.4%).  Table 2 shows that most hospital staff (97.65%) had good knowledge of the baby-friendly hospital initiative, although 57 of them had never received training about it. Table 3 shows that most hospital staff (74.12%) had good perceptions of the baby-friendly hospital initiative, and 62 of them had good knowledge about it.  Table 4 shows that most patients (38.6%) graduated from senior high school, had spontaneous delivery (66,3%), aged 20-35 years old (91.1%), and primiparas (43.6%). Table 5 shows that the hospital had implemented most practices of the baby-friendly hospital initiative based on the 10 steps of successful breastfeeding. Some practices that had not been implemented included skin-to-skin contact (32.67%), breastfeeding in the first hour after birth (29.70%), and breastfeeding support group (38.61%).

DISCUSSION
This study showed that most hospital staff had good knowledge and perceptions of the baby-friendly hospital initiative. However, only a small number of hospital staff (30.6%) had received training on the baby-friendly hospital initiative. Hospital staff has a significant role in promoting exclusive breastfeeding. Good knowledge and perceptions can support the implementation of the baby-friendly hospital initiative at PKU Muhamamdiyah Gombong Hospital. Although not all hospital staff provide direct services for breastfeeding mothers, they contribute to the care of newborns in all settings such as emergency department, central surgical unit, neonatal intensive care unit, and outpatient unit that requires hospital staff who are able to support the breastfeeding process. A good perception of hospital staff is the basic capital for hospitals to implement a baby-friendly hospital so that they will voluntarily carry out the 10 steps of successful breastfeeding. Support from the hospital leaders is also required in implementing the baby-friendly hospital, for example, by providing a nursery room for breastfeeding mothers, roomin policies, and human resources that promote exclusive breastfeeding (Shobo et al., 2020). Mothers need active support to develop their confidence and keep breastfeeding from birth to the age of two. Maternal education, counseling, community mobilization, mass media, and mothers with initiatives to seek information about newborn health are most effective in improving breastfeeding practices. It is in line with the results of this study that most mothers had high school education (4.7%). High education will make it easier for hospital staff to provide health education for mothers. Also, information related to breastfeeding can be provided for mothers and other family members in healthcare facilities (hospitals, health centers, clinics), communities, and families (Benedict et al., 2018).
Hospital staff plays an important role in affecting mothers' behavior and decision to breastfeed. Staff behavior can affect mothers' confidence to breastfeed their babies. Similarly, nurses play an important role in supporting breastfeeding practices. Therefore, the hospital staff's ability is important to improve the overall quality of patient care (Shattnawi, 2017). In this study, all hospital staff who had received materials about the baby-friendly hospital initiative (26%) had good knowledge. Training for hospital staff is important so that they are able to provide optimal breastfeeding support. UNICEF requires hospitals to provide training on general standards for caring for babies so that breastfeeding mothers receive consistent and quality services (Wallace et al., 2018).
This study showed that most hospital staff whose duties were related to breastfeeding mothers were midwives and females (87.1%). The breastfeeding experience of female hospital staff, maternal instincts, and the sense of comfort provide ease for breastfeeding mothers to get information about breastfeeding during hospitalization. One form of support that health workers can do for breastfeeding mothers is to teach them how to position the baby and attach the baby to their breasts during breastfeeding. This procedure will be more easily carried out by female staff (Srimiyati et al., 2021).
Most mothers in this study had spontaneous labor (66.34%). Mothers with spontaneous labor find it easier to do skin-to-skin contact and breastfeed the baby immediately after birth. This result is in line with a study by Vasilevski et al., (2021), reporting that one of the factors affecting exclusive breastfeeding practice during hospitalization is vaginal delivery. Women with vaginal delivery can immediately breastfeed their babies after birth. Immediate breastfeeding affects the success of exclusive breastfeeding. Some specific conditions, such as preterm babies, caesarean section births, and babies who are cared for in a newborn nursery, may have a negative impact on exclusive breastfeeding during hospitalization. Neonates who are not given immediate breastfeeding after birth are less likely to receive exclusive breastfeeding upon discharge from the hospital. The low breastfeeding practice in women with caesarean section delivery may be related to medical complications, interventions that inhibit skin-to-skin contact, pain, and poor postoperative management.
This study showed that PKU Muhammadiyah Gombong Hospital had implemented 7 out of 10 steps for successful breastfeeding practice. Patients stated that the hospital did not give gifts in the form of formula milk (86.14%). Gifts of formula milk and discounted prices for formula milk are often obstacles to exclusive breastfeeding. The promotion of formula milk is related to exclusive breastfeeding practices. Mothers who are exposed to formula milk promotion have a lower chance of giving exclusive breastfeeding to their babies (Maulidiyah & Astiningsih, 2021). Health workers at PKU Muhammadiyah Gombong Hospital have provided information about breastfeeding and the appropriate ways to practice it (82.18% and 74.26%, respectively). One of the health workers' support for breastfeeding mothers is to provide correct information about exclusive breastfeeding and the appropriate ways of breastfeeding (He et al., 2022). Some patients stated that while in the hospital, the babies were not given food and drink other than breast milk (85.15%) and did not use a pacifier (86.14%). Furthermore, mothers could breastfeed the babies as much as the babies wished (82.18%), and there were also facilities for a room-in (81.19%). The practice of room-in provides the opportunity for mothers to breastfeed the baby as the baby wants so that it supports breastfeeding. Using a pacifier is proven to cause some confusion for the baby on the nipple, which prevents breastfeeding in the next period. Health workers should support breastfeeding, one of which is by not giving food and drink other than breast milk unless it is medically indicated (Fresianly Bagaray et al., 2020;Susanthi et al., 2021).
This study showed that three out of 10 steps of successful breastfeeding had not been optimally practiced in the hospital, including skin-to-skin contact (32.67%), breastfeeding in the first hour after birth (29.70%), and giving breastfeeding support group (38.61%). Skin-to-skin contact and immediate breastfeeding after birth are generally carried out through early breastfeeding initiation. This study shows that early initiation of breastfeeding has not been implemented optimally. Factors that become barriers to early breastfeeding initiation include lack of awareness, childbirth, the condition of the baby, nursing factors, and breastfeeding counseling services. Lack of knowledge about breastfeeding benefits, especially regarding colostrum, is a major barrier to starting breastfeeding on time.
Complications of labor, episiotomy, caesarean delivery, and manual removal of the placenta are also barriers to early breastfeeding initiation. The birth of a baby with disabilities also causes psychological pressure on mothers and families and delays in starting breastfeeding. Furthermore, preterm babies and low birth weight babies are also the main causes of delays in breastfeeding. A high workload of health workers may also hinder the early initiation of breastfeeding as well as the unavailability of breastfeeding counseling services in hospitals (Majra & Silan, 2016).
Hospital staff should encourage mothers to join a breastfeeding support group. This support group can be developed by the hospital or in collaboration with other breastfeeding support groups outside the hospital. Postpartum support is positively correlated with breastfeeding success. Health workers should assess mothers' self-efficacy and create positive support to promote successful breastfeeding. In addition, health workers should also assess and emphasize the importance of social support for breastfeeding mothers (He et al., 2022).

LIMITATION OF THE STUDY
This study has a limitation. The readiness to implement a baby-friendly hospital initiative was examined through the hospital staff's knowledge and perceptions, and the patients' views on its implementation, which were measured using questionnaires.

CONCLUSIONS AND SUGGESTIONS
This study identified the readiness of the PKU Muhammadiyah Gombong Hospital in implementing a babyfriendly hospital initiative from the hospital staff's knowledge and perceptions of the baby-friendly hospital and its implementation based on the 10 steps of successful breastfeeding. Most respondents had good knowledge and perceptions of the baby-friendly hospital. Seven out of 10 steps for successful breastfeeding have been implemented in the hospital. Considering the fact that the hospital staff has good knowledge and perceptions of the baby-friendly hospital initiative and most of the steps for successful breastfeeding have been carried out, it could be concluded that the PKU Muhammadiyah Gombong Hospital is ready to implement a baby-friendly hospital initiative. It is recommended that the hospital provides training on the implementation of a baby-friendly hospital for all staff to support breastfeeding in newborns.

ETHICAL CONSIDERATIONS
This study received ethical approval from the Health Research Ethics Committee of Universitas Muhammadiyah Gombong with a reference number of 091.6/II.3.AU/F/KEPK/VIII/2021.

Funding Statement
This study received funding from the RisetMu Grant Batch V from the Central Administrators of Muhammadiyah