Sri Lanka’s Lactation Management Centers

June 13, 2018

In Sri Lanka, as in many other countries, the number of mothers who continue to exclusively breastfeed their child once they leave the hospital drops. Realizing the critical need for breastfeeding support and outreach outside of the delivery ward, Sri Lanka created Lactation Management Centers (LMCs) beginning in 2000 in order to assist mothers who need breastfeeding support. The LMCs, funded by the Ministry of Health, are located in every specialist hospital that provides maternity services and newborn care. They work with in-hospital patients and have a significant outreach component.  The 2012 WBTi report on Sri Lanka cited the LMCs as contributing to high exclusive rates of breastfeeding as mothers receive support on an out-patient basis. Today, Sri Lanka has one of the top breastfeeding outcomes in the world with 99% of children ever-breastfed and 82% breastfed exclusively in the first six months in 2016.


Description & Context

In Sri Lanka, as in many other countries, the number of mothers who continue to exclusively breastfeed their child once they leave the hospital drops. In 2007, 85% of mothers breastfed within the first hour of birth and 53.5% were still exclusively breastfeeding four-five months later (1). Many times, this is due to a lack of education and knowledge of how to breastfeed properly and the importance of breastfeeding, as well as the easy alternative infant formula provides when a mother encounters trouble (1,2). Realizing the critical need for breastfeeding support and outreach outside of the delivery ward, Sri Lanka created Lactation Management Centers (LMCs) in order to assist mothers in need of support (1,3). These LMCs are located in every specialist hospital that provides maternity services and newborn care (1). While there is supervision by a consultant neonatologist or pediatrician, day-to-day operations are performed by Nursing Officers, who have significant breastfeeding training (1). Any mother with problems breastfeeding may use the center for free, without referral letters or appointments (1).

LMCs have a significant outreach component: in addition to looking after any in-hospital patients, Nursing Officers advise through a dedicated phone line in the center, attend to out-patients, present antenatal health educational classes, take part in special day/half-day programmes organized to educate nursing officers staff in other wards, and run sessions for nursing students and midwifery students (1,4). 


Main Components

Guidelines on the construction on Lactation Management Centers are stipulated by the Family Health Bureau (1,7):

  • Space to accommodate 3 cots, 1 bed, 15 arm chairs, duty station, utility area, and other necessary components such as lockers for the mother’s items and a foldable nappy changing area
  • A 24-hour water supply
  • Hand-washing facilities with soap and pictorial hand washing instruction
  • LMC must be open 7 days per week at least from 7 am-5 pm. The facility may be able to operate 24 hours.
  • A telephone hotline for communication.

Staff (1,7):

  • The minimum number of staff for the LMC in small facilities should be 2 officers (2 Nurse Officers or 1 nurse and 1 midwife). Larger hospitals require a staff of 3.
  • Consultant Neonatologist/Pediatrician: Duties include overall supervision, conducting/participating in in-service programs on breastfeeding, specialized opinion if needed, educating the field staff in monthly meetings.
  • Special Care Baby Unit staff: Duties include attending medical problems when request by the LMC nurses, referring mothers and babies identified with feeding problems to the LMC from the SCBU, assisting at training programs.
  • Nursing Officers: Have the most major role and are handpicked by the consulting neonatologist/pediatrician based on good communication skills, kindness, and commitment to promoting breastfeeding. They must receive essential training on breastfeeding, either through the 40 hour WHO/UNICEF Breastfeeding Counseling Course or 20 hour BFHI Course. Duties include doing daily rounds in maternity wards to advise mothers, attending to out-patients, helping mothers express milk, advising outside mothers through a dedicated phone line in the center, presenting antenatal health educational classes, taking part in special day/half-day programmes organized to educate nursing officers staff in other wards, and running sessions for nursing students and midwifery students.

Common Procedures Performed at LMC include (1): 

  • Correcting positioning and attachment
  • Helping and teaching mothers how to express and spoon or cup feed the baby
  • Back massage to stimulate oxytocin release
  • Hot to cold compress when breasts are engorged
  • Using the “syringe method” when the mother’s nipples are inverted/flat
  • Weighing babies and monitoring growth after correcting feeding practices
  • General reassurance, encouragement, and counseling for the mother–debunking any breastfeeding myths and hearing their experience.
  • Subsequent follow up visits are arranged by the nurses.
  • Any medical, surgical or obstetric problems identified at LMC are referred to the hospital medical staff.

Monthly feedback forms are returned to the Family Health Bureau from LMCs all over the country to ensure quantity and quality assurance (1).


Evidence of Implementation Strategy

From 884 admissions to LMCs in 2007, Sri Lanka reported the rate of admissions more than doubled by 2011 (1). In 2012, the WBTi report on Sri Lanka cited the LMCs as contributing to high exclusive rates of breastfeeding as mothers could now receive support on an out-patient basis (5). This report also cites an improvement in Mother Support and Community Outreach, receiving full marks on the criteria, “all women have access to community-based support systems and services on infant and young child feeding” (5).

In addition, LMCs have been reported to significantly reduce the burden on Special Care Baby Units by taking admissions for problems with breastfeeding (8). This can lower costs because Special Care Baby Units have higher costs per cot per day than a normal ward (1). This frees up staff time in the Special Care Baby Unit to focus on immediate life-threatening conditions (8).

Today, Sri Lanka has one of the top breastfeeding outcomes in the world with 99% of children ever-breastfed and 82% breastfed exclusively in the first six months in 2016 (6). It is important to note that there are claims that 82% is an inflated estimate because it is from a 24-hour recall method, where surveyors ask mothers with infants of varying age whether they have breastfed in the last 24 hours (11). 


Cost and Cost-Effectiveness

LMCs are included in universal healthcare system in Sri Lanka. The Ministry of Health (MoH) finances the LMCs through the Family Health Bureau. The MoH has a recurrent budget of approximately 140,000,000 Rupees (USD $910,000) (9). LMCs costs include operating and facility costs, Nurse Officer salaries, and materials needed to encourage breastfeeding and provide for the mother/child (1).

LMCs have been reported to be cost effective by reducing admissions and staffing burdens at the costlier Special Care Baby Units (8). 


Perceptions and Experiences of Interested People

The WHO and WBTi have praised Sri Lanka in its recent gains in breastfeeding practices, citing LMCs as a contributing factor (5). In-country residents also praise the centers; a daily business paper in Sri Lanka, published an article on the opening of a new LMC in 2015, and quoted the Sri Lanka College of Pediatricians President as
stating, “…we know those mothers who fail to breastfeed at the very inception fail to initiate and sustain breastfeeding
within the first week itself. LMCs are manned by trained staff that will help those mothers who have genuine problems in initiating and maintaining breastfeeding” (4).

Furthermore, a study on LMCs in India says that constant reinforcement and support for all mothers is essential to maintain breastfeeding (2). While this role can be filled by mother support groups in the community, in situations these groups are not available or mothers need specially trained help, hospital-based support services, such as LMCs, are a proven method to help mothers (2). 


Benefits and Potential Damages and Risks

  • The LMC staff must be adequately trained on proper breastfeeding practices. Without this training, the Nurse Officers may promote unhealthy practices or be unsuccessful in helping a mother breastfeed. The stipulation that Sri Lankan LMC Nurse Officers receive essential training on breastfeeding, either through the 40 hour WHO/UNICEF Breastfeeding Counseling Course or the 20 hour BFHI Course reduces this risk (1). Re-training should also occur regularly.
  • The benefit of the telephone hotline and in-person demonstration and help are both great benefits of this intervention.  The direct communication between mothers and staff mean questions can be quickly answered, doubts assuaged, and can prevent mothers from turning to formula feeding when problems arise.

Scaling Up Considerations

  • The LMC staff must be adequately trained on proper breastfeeding practices, through a model similar to the 40 hour WHO/UNICEF Breastfeeding Counseling Course or the 20 hour BFHI Course. Re-training should also occur regularly.
  • The Nurse Officers must have not only technical breastfeeding expertise, but personality characteristics to encourage a warm environment. They must have excellent communication skills, and a friendly and encouraging demeanor. A study in India on mothers who have trouble breastfeeding state that emotional support and encouragement is key to the mother’s success (2).
  • While the MoH finances the LMCs in public hospitals, the WBTi report for Sri Lanka in 2012 recommends adding LMCs to private hospitals to reach more populations (5). 

Barriers to Implement

  • While many factors are modifiable to help mothers breastfeed, a Sri Lankan 2016 report on LMCs states that some factors are not changeable, like the time and stress associated with employment, illness of the mother, previous experience breastfeeding, or undergoing operative delivery (10).
  • A shortage of staff in public hospitals may make LMCs unfeasible, as oversight from Neonatologist/Pediatricians and Special Care Baby Unit health workers is required, as well as full-time Nurse Officials to staff the center.
  • The experience in Sri Lanka suggests that the pediatrician/neonatologist be the primary driver of an LMC operating efficiently and effectively.

Equity Considerations

Ensuring that LMCs reach the whole population, especially rural, poor mothers, should be considered with this intervention.


References:

1.                   Wickramasinghe, S. (2012). Lactation Management Centres: A Step Forward in Successful Breastfeeding. Sri Lanka Journal of Child Health, 41(2). Retrieved from http://sljch.sljol.info/articles/abstract/10.4038/sljch.v41i2.4397/2.  Nanavati, R. N., Mondkar, J.A., Fernandez, A.R., Raghavan, K. R. (1994). Lactation Management Clinic-Positive Reinforcement to Hospital Breastfeeding Practices. Indian Pediatrics, 31(1). Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.489.323&rep=rep1&type=pdf

2.                   Healthy Sri Lanka. (2013). Breastfeeding: Lactation Management Centers. Retrieved from http://www.healthysrilanka.lk/healthy-eating/age-related-guide/breast-feeding#TOC-Lactation-Management-centers

3.                   Daily FT. (2015). Pears, College of Paediatricians open Lactation Management Centre at Dambulla Base Hospital. Retrieved from http://www.ft.lk/article/398489/Pears--College-of--Paediatricians-open-Lactation-Management-Centre-at-Dambulla-Base-Hospital

4.                   World Breastfeeding Trends Initiative, IBFAN. (2012). WBTi Sri Lanka Report. Retrieved from http://www.worldbreastfeedingtrends.org/GenerateReports/report/WBTi-Srilanka-2012.pdf

5.                   Sri Lanka Department of Census and Statistics. (2017). Sri Lanka Demographic and Health Survey 2016. Retrieved from http://www.aidsdatahub.org/sites/default/files/publication/SriLanka_DHS_2016.pdf

6.                   Ministry of Health. (2013). Lactation Management Centres (LMC): Standard Guidelines to set up a Lactation Management Centre.

7.                   Wickramasinghe, S.C., Dharmaratne, T.M.S.M. & Wickramasinghe, W.A.C.S. (2014). Establishment of a Lactation Management Centre at Teaching Hospital, Kandy and its Impact on Admissions to the Special Care Baby Unit. Sri Lanka Journal of Child Health 43(3), pp.159–162. Retrieved from https://sljch.sljol.info/articles/abstract/10.4038/sljch.v43i3.7376/

8.                   Sri Lanka Ministry of Finance. (2017). Budget Estimates 2017. Retrieved from http://www.treasury.gov.lk/documents/10181/315287/English_Draft_Vol_2.pdf/37030606-9dda-4be2-b03e-ad0eae81ff05

9.                   Fernando, T. S. M., Prathapan, S., Fernando, R. H. M. (2016). Factors Affecting Difficulties in Breastfeeding in Mothers Attending Selected Lactation Management Centers in Colombo District. Journal of the College of Community Physicians of Sri Lanka, 22(1).

10.               Agampodi, S. B., Agampodi T. C., de Silva, A. (2009). Exclusive Breastfeeding in Sri Lanka: Problems of Interpretation of Reported Rates. Int Breastfeeding Journal, 4(14). Retrieved from  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2789039/

Submitted by Katie Doucet on June 13, 2018