Matter of choice

The nine months of pregnancy is the right time to start thinking about how to feed a baby

While breastfeeding is considered to provide more nutrition and protection, women must be given information about the choices and support for their decisions.

About 26 million babies are born in India every year and yet too few women make informed decisions on feeding their babies. The Government of India’s new programmes to reduce maternal and infant mortality, which includes antenatal counseling, can make a big difference saving the lives of thousands of children and their mothers.

A recent survey conducted by the Facebook group Breastfeeding Support for Indian Mothers showed that more than 50% of women who delivered in private hospitals were introduced to infant formula at birth and out of these in two thirds cases, it was given without their consent. Women are often told to feed their babies formula thinking that they do not produce enough milk. This perception is largely due to either because of lack of skills of health workers working with these women or myths propagated by baby food industry.

Use of any kind of infant formula during infancy is related to increased risk of infections like diarrhea and respiratory disorders in newborn babies. To reduce such risks World Health Organisation advises that: “In situations where infants are not breastfed, caregivers, particularly of infants at high risk, should be regularly alerted that [powdered infant formula] is not a sterile product and can be contaminated with pathogens that can cause serious illness; they should be provided with information that can reduce the risk”.

The government’s routine health package of an antenatal check includes counseling on breastfeeding with the aim of having all women breastfeed. But the recent NFHS 4 data shows that only 41.6% are breastfed within the first hour of birth and only 54.9% infants are exclusively breastfed. That means half the country’s infants are given artificial feeding, of which formula is quite common. According to a Euromonitor Report, 10,847 tonnes of standard infant formula or milk powder for the age group of zero to six months was sold in India in 2012. This means that India sells about 27 million containers of 400 gms every year. Going by the estimated growth of formula industry in 2022, this figure will be 32.7 million.

The latest National Family Health Survey shows that about 80% of all the births in the country take place in medical institutions and a little more than 50% in public institutions. This implies that about 30% occur in private institutions. It is at these private institutions that many infants are given powdered infant formula without heed to the WHO’s guidelines on acceptable medical reasons for giving substitutes. The WHO recommends that once constituted infant formula should be consumed immediately and not after a couple of hours. Prepared feeds provide ideal conditions for bacteria to grow, especially when kept at room temperature. Feeds that are prepared for use later must be refrigerated and discarded if not used within 24 hours.

Disseminating information

Pregnancy, especially the second and third trimester, is the opportune time when women can be given information between the choices of breastfeeding and formula feeding.

The recent Pradhan Mantri Surakshit Matritva Abhiyan announced by Prime Minister Narendra Modi aims at reducing maternal and infant mortality rates through safe pregnancies and safe deliveries. This initiative is the perfectly channel through which to introduce a “baby or infant feeding decision during pregnancy” programme. This would include skilled counseling support that continues into birthing and later.

Most women who give up breastfeeding usually do so due to psychological factors that interfere with success of breastfeeding not because of biological or physiological factors.

A mother who decides to breastfeed needs to be supported both mentally and physically. The efforts should start from the antenatal period by counseling her on the breastfeeding benefits to her and her baby. There needs to be counseling to build a woman’s confidence so that she can breastfeeding without any hindrance and support for the woman if a problem should arise. Reassurance during pregnancy is essential because a woman has a lot on her mind at this time.

Some women face difficulties in allowing infants to attach to to the nipple as well as breast conditions like breast engorgement, inverted nipples and mastitis. While there problems are entirely preventable and require only some practical help, they often become reasons for introducing formula feeding after birth. Counseling families and creating a positive family environment is also crucial to this process.

Support for formula-feeding mothers

A mother who decides to formula feed needs more support so that she is aware and prepared for the risks it entails. She must be provided information on how sterile or not infant formula is, the time it takes for contamination of formula, nutritional quality and content, and short- and long-term health implications. She should also be told to follow the WHO guidelines on how to prepare formula for bottle-feeding at home such that it is safe for the newborn.

Women should have the option of feeding their babies as they choose but before they make that choice they should be fully aware of the options. It is also essential that everyone respect this choice and women be supported to implement that their decisions.

The Infant Milk Substitutes Feeding Bottles, and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992, and its amendment in 2003 recommends providing unbiased information on both breastfeeding and formula feeding. The Act also suggests that all the educational material, whether audio or visual, dealing with prenatal or postnatal care include clear information on benefits and superiority of breastfeeding, preparation for and the continuance of breastfeeding for at least six months, the harmful effects on breastfeeding due to the partial adoption of bottle feeding, the difficulties in reverting to breastfeeding of infants after a period of feeding by infant substitutes, the financial and social implications in making use of infant milk substitute and feeding bottles and the health hazards of improper use of infant milk substitutes and feeding bottles.

Women can be given all this information in just one counseling session under the Pradhan Mantri Surakshit Matritva Abhiyan. This may be done through face-to-face counseling and through reading materials. Keeping safety of infant health as the primary outcome, this sessions should be followed by a decision-making session to help a woman choose between breastfeeding and formula feeding. The decision can be recorded and passed on the health facility where she is going to give birth to her baby.

The writer is a paediatrician and founder of the Breastfeeding Promotion Network of India.

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What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

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Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.