Hospitals help more Singapore mothers breastfeed their babies

SINGAPORE - Singapore is on its way to becoming a country with more babies bred on breast milk, with the National University Hospital (NUH) becoming the first hospital here to be accredited internationally as baby-friendly.

This means NUH is following the 10 steps of the Baby-Friendly Hospital Initiative (BFHI) to encourage its maternity ward patients to breastfeed and to help them do so.

NUH joins 16,000 hospitals in 171 countries certified by the World Health Organisation and United Nations Children's Fund since the initiative began in 1991.

Four other hospitals here - the Singapore General Hospital (SGH), KK Women's and Children's Hospital (KKH), Thomson Medical Centre and Mount Alvernia Hospital - have also implemented all or many of the 10 guidelines and are working towards attaining the accreditation.

The 10 steps may be the same for all these facilities but the challenges can be different, depending on the number of births the respective hospitals handle.

Their efforts are paying off.

At NUH, the proportion of new mothers who breastfed their babies while hospitalised reached 86 per cent last year, up from 75 per cent (the minimum level stipulated by BFHI) in 2011 and just 54 per cent in 2007.

At SGH, which is aiming for BFHI assessment by early October, about 75 per cent of the mothers who delivered in June breastfed their babies, up from 44 per cent who did so in June last year.

A spokesman for Thomson Medical Centre, which targets to attain the BFHI accreditation next year, said: "Close to 85 per cent of our patients continue to breastfeed their babies four to six weeks after delivery. This is a 2 per cent increase compared with last year, reflecting a slight rising trend in mothers who choose to breastfeed."

The proportion of mothers who initiated breastfeeding at Mount Alvernia Hospital, which has been progressively implementing the BFHI guidelines since 2000, has risen to nearly 96 per cent this year, from 93 per cent in 2009.

Ms Tay Hai Gek, its assistant director of nursing, said: "Currently, some still do not fully embrace the notion that breastfeeding is best. While we strongly support the BFHI, we also need to respect individual beliefs and preferences."


After preparing for six years, NUH applied for the accreditation in March and was certified on Aug 1.

Dr Yvonne Ng, consultant at the department of neonatology at NUH who chaired its BFHI steering committee, said: "Becoming BFHI-accredited shows that NUH has achieved international standards to support successful breastfeeding.

"Our primary objective is to support all mothers to exclusively breastfeed their newborn babies for six months and to continue breastfeeding for two years, for optimal health of mother and baby."

The WHO recommends exclusive breastfeeding of babies from birth till six months.

After that, solid food should be introduced to complement breastfeeding for two years or more.

Breast milk is the best food for babies as it is easy to digest, provides all the nutrients they need and contains antibodies that protect them from common childhood illnesses. It may even boost their intelligence.

Breastfeeding also helps women to lose their pregnancy weight faster and reduces the risks of breast and ovarian cancer later in life.

Despite these benefits, many mothers find it difficult to breastfeed their babies exclusively, often due to insufficient support or because they had received the wrong advice.

The BFHI requires that mothers attend antenatal education classes at the hospitals.

Dr Mythili Pandi, president of the Breastfeeding Mothers' Support Group in Singapore, said: "Sadly, many Singaporeans do not yet see the benefits of attending these classes. It's scary because some people do not have an adequate understanding of breastfeeding and may not give the correct advice."

Dr Yong Tze Tein, senior consultant at the department of obstetrics and gynaecology at SGH, said: "Many mothers worry about not having sufficient milk but feeding frequently will help build their supply."

The more a mother breastfeeds, the more milk her body will be stimulated to produce.

Others worry that night feeds will disrupt their much-needed sleep. But this may not be true. Dr Yong said: "Interestingly, some studies have shown that formula-feeding mothers do not get more sleep compared with breastfeeding mothers."

Dr Ng said: "Breastfeeding may be a natural part of motherhood, but it may not be easy for some mothers.

"Mothers who deliver at NUH will be in an environment where breastfeeding is regarded as normal practice, and will receive consistent support from trained staff, which is especially helpful for mothers facing challenges while breastfeeding."


A BFHI strategy to help mothers establish breastfeeding and bond with their babies is to get mothers to be with their babies 24 hours a day, a practice termed as rooming-in, during the hospital stay.

But this is often a big challenge. Many mothers do not wish to do so. They ask: Why should they room in with their babies when nurses are around to help them?

Dr Yong said: "Mothers here have the idea that after delivery, they need to rest as much as possible and some are not open to the idea of rooming in with their newborn babies as they worry that they will not get enough rest.

"What many fail to appreciate is that if they room in, it will greatly help them learn the feeding cues and feed more often and they are more likely to succeed in breastfeeding. This will also help them adjust to how it would be like at home."

She said that babies sleeping close to their mothers are calmer and cry less as mothers respond faster to their needs.

On top of the resistance towards rooming-in, the other main challenge at KKH is getting mothers to breastfeed exclusively, revealed Dr Chua Mei Chien, senior consultant at its department of neonatology.

She said: "A proportion of mothers prefer to subsequently practise mixed feeding with formula supplementation. Some mothers choose to replace some of the night feeds with formula milk so that they can rest. They also believe that the baby will sleep better when formula is fed at night."

Some may also have the misconception that breast milk production is insufficient in the first few days after giving birth to meet the baby's needs and, hence, they need to supplement breast milk feeds with formula until the milk flow is established.

In fact, all these practices will delay and interfere with the establishment of an adequate milk supply, she said.

KKH is working towards a shift in mindset by continually educating mothers-to-be on the benefits of breastfeeding, she added.

NUH has not experienced many problems with getting mothers to breastfeed exclusively in the past few years as their trained nurses have been providing consistent guidance and support in the practical aspects of exclusive breastfeeding, said Dr Ng.

It promoted the concept of rooming-in to parents as the best way for them to bond with and get to know their babies, as well as to facilitate breastfeeding, she said.

Another aspect of a BFHI criterion - to initiate breastfeeding within half an hour of giving birth - involves early skin-to-skin contact between mother and child. The contact calms and relaxes mother and baby and stimulates feeding behaviour and the release of hormones to support breastfeeding.

But both health-care staff and parents had initial reservations about this. "Without prior preparation or knowledge about this, parents would expect their newborn baby to be handed to them fully clothed, swaddled in a blanket, and after nurses and doctors have completed their routines," said Dr Ng.

NUH doctors and nurses modified their practices to facilitate the contact, said Dr Ng. Now, immediately after delivery, the baby will be placed upon the mother's chest while she is in the operating theatre. In the past, this was done only when she was waiting to be wheeled to the recovery area.

Among those who have benefited from this practice is Dr Lilian Chee (with her second child George), 42, an assistant professor at the National University of Singapore, who started breastfeeding immediately after she delivered George about 14 weeks ago at NUH.

"The operating theatre staff brought him to me within minutes of delivery. The skin-to-skin encounter was a wonderful experience, which I feel, made a great difference to our closeness," she said.

She and her husband roomed in with George, as they did with their first child, Joan, now three, who was also born at NUH.

She recalled that the experience was scary at first, but after they became used to it, they missed Joan when she was not with them.

"It is also a good practice to get to know how your baby reacts. You start to realise that he cries differently when he is hungry or sleepy."


Even as hospitals work towards helping more mothers breastfeed, they have to deal with the new challenges that this brings.

Dr Yong said as more mothers choose to breastfeed, they have a new challenge of making sure that the medication prescribed for some of these mothers will not make their breast milk unsafe for babies.

She added: "Unfortunately, there is not much data on certain types of medication."

Gynaecologists, neonatologists and pharmacists at SGH are working together to come up with guidelines and a list of safe drugs, she said.

Hospitals also have to work on helping mothers continue breastfeeding after they have been discharged.

NUH, for instance, provides post-discharge support for breastfeeding via its breastfeeding helpline and early follow-up (within a week) with neonatal doctors and lactation consultants who are well-versed in breastfeeding support.

Indeed, supporting mothers in the first two weeks after they go home is crucial, Dr Yong said.

"Breastfeeding is demanding. Support at home, in terms of help with household chores, moral support and encouragement, is essential," she said.

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