This paper describes the perceptions of the BFHI held by a group of Australian midwives and nurses working in one AHS in NSW, Australia. The findings indicated that, in principle, participants considered the BFHI to be a high priority, an essential set of practices or innovation that would have positive benefits for babies and mothers both locally and globally as well as for health professionals. The perceptions that health professionals and others hold of health innovations such as the BFHI can influence implementation [18
]. However, despite the overall positive perceptions of BFHI, no hospitals in this AHS had applied for BFHI accreditation and further, across Australia only around 23 percent of hospitals with maternity services have achieved this goal [13
] although it is 20 years since BFHI was launched.
Researchers suggest there are barriers to any policy and practice change [18
] including the implementation of strategies to promote and support breastfeeding [15
]. Drawing on the work of Rogers [24
], Greenhalgh [18
] developed a model that suggests that the characteristics of an innovation are important in influencing adoption of the innovation or policy and practice change. They identified a number of characteristics influencing adoption (see Table ) and many of these characteristics are evident in the findings of this study. In the following discussion the results will be explored utilising the work of Greenhalgh and colleagues [18
] to examine the characteristics of the BFHI that may influence its adoption or implementation.
Table 3 Characteristic of the innovation influencing adoption (adapted from Greenhalgh et al)
It is important to note the limitations of this study. This study was conducted in one AHS in NSW, Australia and participation was voluntary and limited to those midwives and nurses interested in attending and available at the scheduled date and time. Participants included two midwives who had worked previously in a BFHI accredited hospital and it may be that their experiences of BFHI could have influenced the views of those participants involved in implementation for the first time, either prior to or during the focus group. It may also be that the perceptions of staff working in hospitals that have BFHI accreditation differ from those who participated in this study. We also recognise that the perspectives of other health professionals who may influence BFHI implementation such as paediatricians, obstetricians, general practitioners, health promotion officers and peer support organisations have not been included in this study. The findings should therefore be interpreted with caution. The scope of this study has precluded interviewing women who are accessing these maternity services, but this is clearly an important perspective and will be the focus of ongoing research.
The Innovation-Relative advantage and compatibility
The BFHI was seen as a way to promote and support breastfeeding thereby, improving the health of babies, pleasing women, families and the community, and making staff happier, suggesting the innovation was perceived as having a 'relative advantage' over current practice or other single interventions or strategies that may be effective in promoting and supporting breastfeeding [25
]. Some participants reported they were influenced by the international research supporting the implementation of BFHI and they attributed increases in breastfeeding initiation and duration rates both locally and globally to the implementation of the BFHI.
In addition, given the professional and public acknowledgement of the importance of breastfeeding to the health of mothers and babies [27
], an innovation such as the BFHI that supports breastfeeding is generally compatible with social and professional norms in Australia. Consequently, there appeared to be no doubt about whether the BFHI should be implemented, rather it was a matter of how, and within what time frame it could be implemented. It was considered achievable but would take commitment and hard work to overcome the numerous challenges and to 'climb the mountain' towards attaining BFHI accreditation.
Trialability and Observability
Greenhalgh et al [18
] also indicate that an innovation is more likely to be adopted if there is an observable benefit to doing so and if the innovation or aspects of it can be trialled prior to full implementation. Participants were heartened in their endeavours to implement BFHI because they were aware that other hospitals had been accredited in Australia. Furthermore, staff from two of the participating maternity units reported that all of the ten steps were already implemented within the maternity unit and with a little more work with other professionals and sections of the hospital they would be able to achieve BFHI accreditation. Both maternity units report breastfeeding rates at discharge from hospital of over 90 percent [30
However, the 'observability' of the benefits of BFHI is yet to be established in the Australian context. While acknowledging the positive effect of the BFHI in increasing breastfeeding in countries with low initiation and duration rates [31
], there is little evidence to date to suggest the implementation of the BFHI in Australia will have a positive effect on breastfeeding rates particularly increased duration rates [34
]. Participants also noted that some of the outcomes of BFHI, for example the long term health impact of the minimisation of artificial feeding in hospital, would not be observable to those implementing BFHI and therefore decreases the impetus to implement BFHI.
Complexity and task focused
The less complex an innovation is, the more likely it will be adopted. BFHI is a complex innovation, and the perceived complexity of implementing and evaluating BFHI is reflected in the number of studies that have trialled one or two components of the BFHI, for example the introduction of professional education to support breastfeeding [23
] and skin to skin contact in the first hour after birth [37
]. However, this indication of complexity also illustrates how the developers of BFHI used a classical simplification process of breaking the innovation down into more feasible parts (steps). This is demonstrated in the analysis where the participants discussed their achievements in implementing some of the steps and identifying where further work was required. For example, steps 4, 6, 7 and 9 related to the practice of skin to skin contact and restricting use of infant formula or pacifiers appeared easier to implement than steps 2, 5, 10 which involve staff having time to provide breastfeeding education and support for women (lack of time to to meet the information and support needs of breastfeeding women is common [39
Reinvention and fuzzy boundaries
Greenhalgh et al [18
] suggest that innovations that are flexible or able to be adapted to the particular needs of the organisation so that it meets the clients' needs or the needs of staff are more likely to be adopted. In this study some participants expressed concern that the BFHI represented a set of rules that health professionals had to apply in the same way in all settings, with all women and babies. According to the participants there appeared to be little space for reinvention or flexibility in service provision. Furber and Thomson [40
], in the UK, also report that midwives 'break the rules' in order to support mothers in what they perceived as beneficence. The apparent inflexibility of BFHI may therefore be a barrier to its implementation.
Greenhalgh et al [18
] indicate that an innovation will often need additional organisational support which may range from endorsement, to provision of additional resources to support implementation. This study found that while BFHI had endorsement at State level, participants were concerned that there was no additional organisational or institutional support for implementing BFHI; this meant that institutional priorities, such as freeing up 'bed block,' were more important than ensuring that a woman felt confident with breastfeeding before discharge. In this site, no one person or group had a mandate to implement the BFHI, which Walsh et al [13
] believe is crucial to implementation and comprises part of the accreditation process. It is also difficult to ascertain the financial costs associated with BFHI implementation and accreditation and, to date, there has not been a cost benefit analysis of BFHI. The NICE guidelines on postnatal care [41
] suggest that the cost of preparing a BFHI implementation plan and the initial assessment is approximately 6,000 UK pounds. This does not include the cost of a BFHI coordinator or the significant cost of ensuring all staff is trained.
Adoption by Individuals- The meaning
There were differences in the perceptions and interpretations of BFHI across participants. Greenhalgh et al [18
] stated that the meaning of an innovation to individuals was important to its adoption. Whether an individual's understanding of the innovation fits with the understandings of managers, service users, and other stakeholders will affect individual adopters. Different perceptions could potentially lead to unfulfilled expectations and disillusionment with the innovation. In this study some participants appeared to raise the status of the BFHI to that of a 'saviour' of breastfeeding and thereby a strategy that would increase health and well being of children and adults both locally and globally. For most participants, however, the BFHI was perceived as a list of tasks to be achieved.
Participants also tended to equate the BFHI with breastfeeding promotion. Rather than the BFHI being a strategy to improve the practices of health professionals within the hospital setting, it was interpreted as a strategy to convey the key message to mothers that 'breastfeeding is the normal way to feed a baby'. In this way the BFHI was seen as influencing infant feeding decisions. Some participants interpreted this to mean that women were given little choice in their feeding method and that they may be, or were being, pressured to breastfeed. Staff concerns about pressuring women to breastfeed has been reported by others [40
] and many studies have reported women feeling pressured to breastfeed by midwives [28
]. This lack of understanding of the BFHI could clearly lead to difficulties in BFHI adoption as individuals may be opposed to BFHI implementation based on their (mis)perceptions of what being 'Baby Friendly' involves rather than what it actually does involve.
In summary, the findings of this study were explored within the context of two aspects of Greenhalgh [18
] model for diffusion of innovations-the innovation and the adoption by individuals. From the findings BFHI as an innovation has:
• relative advantage to midwives, mothers and babies
• apparent compatibility with the midwifery philosophy of practice
• complexity, but is broken down into steps for easier adoption
• trialability-it has already been adopted by others
• observability of its benefits has yet to be established in Australia
• limited reinvention-the BFHI was perceived as being non-modifiable
• clear not fuzzy boundaries although at time these boundaries appeared to be too rigid
• limited augmentation and support for the BFHI by the organisation and managers
Adoption by individuals:
• the meaning of the BFHI to individuals influenced its implementation, for example the BFHI was viewed as a saviour or a burden.