Baby-Friendly e-Newsletter : Baby Friendly Watch (December 2021)

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Ensuring Staff Competency to Support Breastfeeding


Dr Patricia Ip
Chairperson, Committee on Designation of Baby-Friendly Health Facilities,
Baby Friendly Hospital Initiative Hong Kong Association (BFHIHKA)



The WHO/ UNICEF launched the Baby Friendly Hospital Initiative (BFHI) in 1991. The evidence for the BFHI was updated in 2017.1 In 2018 the implementation guidance based on the updated evidence was published, including the revised Ten Steps to Successful Breastfeeding (Ten Steps).2 This was summarised in a previous BFHIHKA newsletter.3 Central to the success of the BFHI is health care staff with the competency, i.e., the related knowledge, skills and attitude, for its implementation. The WHO prepared a Competency Verification Toolkit (the toolkit)4 in 2020 to assist facilities which are joining or have joined the programme. Below is a brief description of the toolkit and some related resources.


Revised Step 2 of the Ten Steps

“Train all health care staff in skills necessary to implement the policy” to “Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding”

The revised Step 2 shifted the focus from hours of training to verification of competency, i.e., from process to outcome. This paradigm shift was explained by the team that devised the toolkit in a recent article.5


Ensuring Competency

Health care staff is expected to have had basic training on breastfeeding either pre-service or in-service. The WHO 3-day BFHI training course for maternity staff6 has been revised in the light of the revised Ten Steps with the inclusion of all newborns in the programme rather than only healthy term infants. For the application of BFHI to small, sick and preterm newborns, the WHO/ UNICEF had published a supplementary guidance in 2020.7

The BFHI is a continuous quality improvement programme. The quality improvement cycle can be applied to the process of ensuring competency. The health care facility identifies a goal or set of goals it wants to achieve. It then plans, implements the plan, monitors or studies the outcome and takes action so that the goal(s) could be achieved. Hence the facility decides which staff performance areas need enhancement, conducts baseline assessments, targets training in these areas, reassesses, and plans further actions as necessary.


Competency Verification Toolkit 

Instead of the 20 competencies identified in the WHO 2018 guidance2 for Step 2, the toolkit has rearranged them into 7 domains with 16 competencies as some previous competencies were considered beyond the scope of BFHI. There are also 64 performance indicators which are specific and action-oriented to document the staff having acquired the competencies.

Domains and Competencies

Domain 1: Critical management procedures to support the Ten Steps

  • 01. Implement the Code in a health facility
  • 02. Explain a facility's infant feeding policies and monitoring systems

Domain 2: Foundational skills: communicating in a credible and effective way

  • 03. Use listening and learning skills whenever engaging in a conversation with a mother
  • 04. Use skills for building confidence and giving support whenever engaging in a conversation with a mother

Domain 3: Prenatal period

  • 05. Engage in antenatal conversation about breastfeeding

Domain 4: Birth and immediate postpartum

  • 06. Implement immediate and uninterrupted skin-to-skin
  • 07. Facilitate breastfeeding within the first hour, according to cues

Domain 5: Essential issues for a breastfeeding mother

  • 08. Discuss with a mother how breastfeeding works
  • 09. Assist mother getting her baby to latch
  • 10. Help a mother respond to feeding cues
  • 11. Help a mother manage milk expression

Domain 6: Helping mothers and babies with special needs

  • 12. Help a mother to breastfeed a low-birth-weight or sick baby
  • 13. Help a mother whose baby needs fluids other than breastmilk
  • 14. Help a mother who is not feeding her baby directly at the breast
  • 15. Help a mother prevent or resolve difficulties with breastfeeding

Domain 7: Care at discharge

  • 16. Ensure seamless transition after discharge


The second domain of foundational skills for effective communication and counselling applies throughout the other domains. Health care workers are not only to be able to support breastfeeding clinically but women's informed decisions, respecting them as partners in care.

For the performance indicators, each is clearly stated as to its relationship with which competency and BFHI Step, whether one or more competencies of knowledge, skills and attitudes are being assessed and which means of verification could be used.


Competency Verification Forms

There are two sets of competency verification forms with the same performance indicators but sorted by domain and competency or by BFHI Steps. Facilities could elect to use the former when developing training or the latter if the facility wishes to improve a certain BFHI Step or set of Steps. The form can be used to record each health care worker’s competencies and provide feedback to the worker to guide future learning. Being verified to be competent could enhance staff confidence, accountability and professional pride.


Assessment Tools and Related Resources

The toolkit provides various tools to verify staff competency. There is a set of 64 multiple choice questions to verify staff's basic knowledge. Answer keys with explanation for the appropriate responses are included. A number of case studies and observation tools are also provided to help assess knowledge, skills, attitude and logical thinking for various clinical situations involving different performance indicators. There is the option to add or modify questions and expected responses to suit local policies, guidelines and the use of language.

There are resources for examiners to assist and guide them or to train new examiners. These contain appropriate responses with references should the examiner require further information.

To distinguish between internal and external assessments, internal assessments are done by examiners and external assessments by assessors. Facilities should identify examiners who are able to stimulate professional growth while identifying gaps through the exercise of competency verification. They should be knowledgeable about what is correct and incorrect, be observant and possess interviewing skills, able to probe without influencing results and are accurate recorders.


Use of the Toolkit 

The toolkit can be used as a whole or for certain Steps. Health care workers can use the multiple-choice questions for self-assessment. The facility can use the toolkit to assess individual staff or teams of a unit or across units. It can also be used before designing training or when preparing for external assessment.


Way forward

For institutions responsible for the pre-service and in-service training of healthcare professionals, the training curriculum should be revised according to the WHO revised Ten Steps. The toolkit can serve to identify gaps and training needs at the individual, departmental and institutional levels. 

For the assessment of Baby-friendly health facilities, the WHO is in the process of preparing new external assessment tools based on the revised Ten Steps. Currently BFHIHKA is performing external assessments using the existing WHO tools for facilities already enrolled in the BFHI programme but will consider revising the assessment criteria for new facilities joining the programme and for revalidation. Any changes will be announced in advance on BFHIHKA's website.


Key Messages:

1.  Ensuring staff competency is central to the success of BFHI.



2.  The WHO Competency Verification Toolkit facilitates the targeted training and assessment of health care workers.



For the note of References, please click PDF version.


Editor-in-Chief: Dr Shirley Leung


All rights reserved by Baby Friendly Hospital Initiative Hong Kong Association.



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