Background
Reduction of newborn mortality through improved newborn care is a global health
priority. Each year, 15 million infants are born prematurely (Chawanpaiboon et al.,
2019), leading to 1
million deaths due to complications associated with prematurity (Liu et al., 2016),
the
leading cause of neonatal mortality globally. Sustainable Development Goal Target
3.2 (UNICEF, 2017) calls
for countries to reduce neonatal mortality from 19/1,000 live births in 2016 to
12/1,000 by 2030. However, many countries are not on target to achieve this (United
Nations, 2020).
Through improved global recognition and alignment of newborn care practices,
including Every Newborn Action Plan (World Health Organization
[WHO] & United Nations Children’s Fund [UNICEF], 2014) and Early Essential Newborn
Care ([EENC]; WHO,
2018), facilities worldwide are seeking meaningful, sustainable, and
cost-effective models for improving newborn health.
Breastfeeding is one of the most powerful interventions to save infant lives globally
(Victora et al.,
2016). When breastfeeding or provision of mother’s own milk is not an option
or is not available in sufficient supply for low-birthweight infants, due to
maternal morbidity or mortality, abandonment or separation, or maternal milk still
coming to volume, the World
Health Organization (2011) recommends the provision of pasteurized donor
human milk (PDHM) from a human milk bank (HMB), as superior to formula. A HMB is
defined as a service established to recruit human milk donors, collect donated milk,
and then process, screen, store, and distribute the milk to meet infants’ specific
needs for optimal health (PATH,
2019a). Provision of donor human milk (DHM) compared to formula improves
health outcomes (particularly through the prevention of necrotizing enterocolitis)
among vulnerable neonates, especially those preterm and low birth weight (Arslanoglu
et al., 2013;
Boyd et al., 2007;
Cacho et al., 2017).
Researchers have demonstrated that implementation models which achieve the
integration of a HMB into systems for protecting, promoting, and supporting
breastfeeding are most effective (Arnold, 2006; Arslanoglu et al., 2013, DeMarchis
et al., 2017; Israel-Ballard, 2018). Yet,
global guidance and standards about the implementation of HMB systems is limited.
Recommendations for best practices on integration of HMB systems into high-level
neonatal care facilities to protect, promote, and support optimal breastfeeding
practices are vitally needed to ensure that mothers receive lactation support and
that PDHM is not used inappropriately (PATH, 2019b).
Although nearly 700 HMBs exist globally, the majority are in Europe; South, Central
and North America; and some countries in Asia (PATH, 2019a). Most low and middle-income
countries (LMIC), settings with a high burden of neonatal morbidity or mortality,
do
not have even one HMB and guidance specific to adapting HMB systems to LMIC settings
is limited (PATH, 2019a).
This manuscript describes the successful experience of establishing the first HMB
in
Vietnam and the lessons learned that could be applied to a regional expansion.
Vietnam is an optimal location for establishing an integrated HMB. It is a country
in
Southeast Asia with a population of 95 million. Each year, out of 1.6 million
births, 19,000 infants die within the first 28 days of life (41% due to
prematurity), which represents 70% of the country’s infant deaths and 55% of deaths
under 5 years of age (UNICEF,
2017). Vietnam faces challenges with achieving optimal infant feeding:
26.5% of infants achieve early initiation of breastfeeding, and 24.3% of infants
under 6 months are exclusively breastfed (UNICEF, 2017). In Vietnam, formula has been
used in the neonatal unit in some instances for more than 50% of admitted infants
(Tran et al., 2018).
Vietnam has prioritized neonatal health and nutrition, and implemented multiple
initiatives, including the WHO and UNICEF action plan initiated in 2014 to increase
the prevalence of breastfeeding (i.e., enactment of Decree 100—a legal document—to
regulate trading and use of nutritional products for infants, as well as feeding
bottles and dummies), strengthen Baby-Friendly hospitals, and ensure Early Essential
Newborn Care (EENC) practices (Vietnam Government, 2014; World Health Organization,
2014, 2015). Vietnam extended
paid maternity leave to 6 months (Vietnam National Assembly, 2012a) and
applied strong regulation on trading in and use of manufactured nutrition products
for infants, feeding bottles, and teats (Vietnam Government, 2014; Vietnam National
Assembly,
2012b). In this context, Vietnam sought to establish the country’s first
human milk bank (HMB), as part of its comprehensive strategy to ensure all infants
receive human milk and to improve newborn care.
Key messages
Donor human milk from a human milk bank is recommended for low
birthweight and premature infants when mother’s own milk is not
available.
A systematic, phased approach is an effective mechanism for establishing
safe, quality, and locally appropriate human milk banking systems and to
ensure that provision of donor human milk is integrated into clinical
use.
Ownership by the hospital implementing a human milk bank, complimented
with local and national support, is necessary to create a human milk
banking system to support those most in need.
The systematic and stepwise approach used for implementing the first
human milk bank in Vietnam serves as a model for scaling up where
systems did not previously exist.
The Development and Establishment of the First Human Milk Bank in Vietnam
The Danang Hospital for Women and Children (DNHWC), designated as one of the three
WHO Centers of Excellence for EENC (Nguyen et al., 2018), was selected as the
site for the first HMB in Vietnam. The DNHWC is a referral hospital responsible for
technical support and the supervision of district hospitals in Danang, and in other
provinces in central Vietnam. The Danang City Department of Health has a history of
strong breastfeeding promotion, including the launch of provincial franchise
services to provide counseling services on maternal, infant, and young child
nutrition in the region, supported by Alive & Thrive, a global nutrition
initiative (https://www.fhi360.org/projects/alive-thrive; Baker et al., 2013). Each
year, there are
13,000–15,000 births at the DNHWC, with 350,000 outpatient visits and inpatient
treatment cases, and over 30,000 women and 50,000 pediatric patients (Nguyen et al.,
2018). The
hospital’s neonatal unit provides treatment each day for approximately 120 babies
with low birth weight, premature birth, or illnesses (Nguyen et al., 2018; Tran et
al., 2015). Providing the best
health services for women and children is the main objective of the hospital,
including breastfeeding promotion and support. The neonatal unit applies Kangaroo
Mother Care (KMC) guidelines for preterm and low birth weight babies, and complies
with Decree 100. The staff also support capacity building activities related to KMC,
EENC, and Integrated Management of Childhood Illness for staff in DNHWC, and other
hospitals in Vietnam, as well as in other countries (Nguyen et al., 2018).
To detail the process involved in establishing the first HMB in Vietnam, we reviewed
project documents, monitoring system reports, and project progress reports to
capture activities performed, modifications made, and lessons learned throughout the
project. We also reviewed findings from the facility assessment, formative
assessment, baseline and other feeding assessments, and the costing assessment,
along with the updates made to the standard operating procedures. We detail the
early implementation of this project from November 2015 through April 2017. The
results represented here are the summarized actions that were pivotal for the
successful implementation and integration of the first HMB in Vietnam.
The implementation process involved establishing a multi-stakeholder partnership
among the Ministry of Health (MoH), Danang City Department of Health, DNHWC, Alive
& Thrive, and PATH, a global team of innovators working to eliminate health
inequities (https://www.path.org). This team employed an
established global model for a multi-phase, systematic approach to integrate a HMB
with newborn care and nutrition programming, by instilling ownership, building
technical competency, and ensuring sustainability and safety (Figure 1; PATH, 2019a).
This built upon the learnings
from past HMB implementations of PATH’s Mother Baby Friendly Initiative Plus model
globally, including in South Africa and India (PATH, 2019a). Comprehensive implementation
involved three key components: building local ownership; implementation of a safe,
sustainable, and data-driven system; and ongoing quality improvement. Building upon
the established global multiphase model, we further expanded to four critical phases
for establishing a sustainable HMB model specifically in Vietnam: 1) induction and
awareness; 2) establishment and technical competency; 3) operation and
stabilization; and 4) expansion of model and sharing results (Table 1).
Figure 1
A Phased Approach for Establishing a New Human Milk Bank System.
Note. This stepwise approach reveals the essential
activities for establishing an integrated, sustainable human milk bank
system in a new setting.
Table 1
Critical Adapted Phases for Establishing a Sustainable Human Milk Bank Model
in Vietnam.
Induction and awareness (November
2015–June 2016)
HMB project initiated and funding
secured
Approval obtained from the Ministry
of Health and Danang People’s Committee
Awareness meetings held with key
technical and policy leaders
Stakeholders met and agreed on the
implementation plan
HMB learning exchange in Glasgow,
Scotland
Project Advisory Committee and HMB
multi-disciplinary team established
Facility assessment completed
Formative assessment completed
Establishment and technical competency
(June 2016–January 2017)
Breastfeeding promotion, protection,
and support components strengthened
HMB facility upgraded and equipment
purchased
HACCP training conducted
HACCP plan developed
HMB guidelines and SOPs
developed
Training on SOPs conducted
Digital information management system
constructed
Baseline feeding study conducted
Costing assessment for establishment
of HMB conducted
Operation and stabilization (February
2017 to date)
HMB launched
Demand generation activities (events,
one-on-one contact, mass media, social network) conducted
Refresher training on SOPs
conducted
HACCP refresher training
conducted
Supportive supervision training
conducted
Ongoing mentorship for quality
improvement implemented
Endline evaluation of HMB (feeding
study and assessing barriers and facilitators to implementation)
conducted
Costing assessment for operation of
HMB conducted
Expansion and sharing (May 2017 to
date)
A Resource Toolkit for Establishing
and Integrating Human Milk Bank Programs—A Global Implementation
Framework Version 2.0 disseminated
Knowledge exchange supported
Technical assistance provided to
additional hospitals in Vietnam and in Southeast Asia
HMB service agreements initiated with
additional hospitals in Vietnam
Note. HMB = human milk bank. HACCP = Hazard Analysis
and Critical Control Point. SOPs = standard operating procedures.
Induction and Awareness (November 2015–June 2016)
Building Local Ownership
The initial phase entailed building ownership and awareness among key
stakeholders. A stakeholder meeting was convened by Alive & Thrive and
PATH in January 2016 to raise awareness among participants from the Maternal
and Child Health Department and the Legislation Department from the MoH,
Danang City Department of Health, UNICEF, an international HMB specialist,
hospital leaders, social media breastfeeding advocates, and media. The chief
neonatologist of the DNHWC, who also serves as the Vice Director of the
hospital, served as a local champion, and built momentum with key
stakeholders at DNHWC and with the Danang City Department of Health. A
Project Advisory Committee, comprised of 10 leaders and staff of the MoH,
Danang City Department of Health, Alive & Thrive, and PATH, was
established to oversee the HMB implementation. The Project Advisory
Committee held quarterly meetings throughout implementation, to agree on
local needs and provide guidance. In addition to the Project Advisory
Committee, a DNHWC multi-disciplinary, hospital based HMB team was
established for integrating, establishing, and operating the HMB. It
included experts in neonatology, nursing, microbiology, infection control,
human milk processing, lactation support, hospital quality control, and
midwifery.
Learning Exchange
Due to lack of established mechanisms for global learning or guidance from
the WHO about establishing a HMB, the team relied on guidance provided
voluntarily by the HMB staff in Glasgow, Scotland. To build technical
competency, MoH, DNHWC, Alive & Thrive, and PATH had a 4-day learning
exchange with the national Greater Glasgow and Clyde Donor Milk Bank in
Glasgow. All HMB processes were shared, including all aspects of quality
control regarding collection, screening, storage, and pasteurization, as
well as the prioritization and appropriate use of PDHM in the neonate unit,
donor recruitment, and the provision of lactation support (including early
initiation of breastfeeding or milk expression and frequent expression for
building maternal milk supply). Additional operational aspects, including
staffing structure, costing, and the sustainability of the national service
were also reviewed. After this learning exchange, Scotland HMB technical
experts continued providing volunteer mentorship through remote and
follow-up visits for on-site support.
Facility Assessment to Evaluate Readiness
A hospital assessment was performed by an international HMB expert from the
United Kingdom and PATH to determine the readiness, barriers, and
facilitators for optimal HMB implementation. Given that no global guidance
existed and that this was the first HMB in Vietnam, an HMB expert with
experience operating a human milk bank and feeding vulnerable infants was
best suited to assess readiness, identify recommended locations, and observe
the steps needed to establish a safe and quality system. The assessment
included a site visit, review of medical records, and interviews with staff
from the neonatal unit and postnatal ward, as well as observations of
neonatal feeding methods. Maternal lactation was observed to be supported
through access to and the support of trained nursing staff for encouraging
breastfeeding and supporting expression, access to a communal breast pump,
and posters with key breastfeeding support messages. The hospital assessment
identified the strategic placement of the HMB within proximity to the public
entrance, with proximal access to the neonatal unit. A review of the
neonatal feeding records revealed that a more in-depth feeding assessment
was needed to serve as a baseline for accurately assessing the enhancement
of support for mother’s own milk and the accurate demand for PDHM.
Formative Assessment to Inform Communication Tools
A formative assessment was conducted to: (1) understand the perceptions and
attitudes of mothers, hospital leadership, and health care providers towards
establishing an HMB in Danang; (2) identify the barriers and facilitators
influencing donation and use of donated human milk, including wet nursing;
and (3) design a behavior change communication and demand generation
strategy for acceptance of the services and to enable donation and use of
safe PDHM. Focus group discussions were held with caretakers of potential
recipients of PDHM, potential donors of DHM, and influencers, including
grandmothers and partners. Technical experts, including health care
providers and breastfeeding advocates were also interviewed.
Emerging key themes from the formative assessment included agreement on the
need for PDHM, existence of milk sharing and wet nursing practices in the
facility setting, and the perception that the donation of human milk was a
humanitarian gesture and payment would not be required. HMB safety, hygiene,
and the appropriate use of PDHM were the most pressing concerns. Based on
the assessments, the HMB team developed a social and behavior change
communication plan. A creative media agency assisted to develop, test, and
produce various promotional products, including the HMB logo, video clip,
posters, leaflets, donor identification/appreciation card, mascot for
demand-generation activities, and recognition gifts for donors, guests, and
volunteers. Social media channels (website, Facebook fan page) and
demand-generation events were effectively used to raise awareness about the
HMB and generate supply and demand. The HMB logo and slogan “sharing
mother’s milk, sharing love” became the key theme throughout. An informative
short video clip on HMB processes and safety was developed and aired on
local television stations, HMB websites, and YouTube.
Establishment and Technical Competency (June 2016–January 2017)
Facility Upgrade and Procurement of Equipment
Lactation support was an essential component of the comprehensive HMB model;
therefore, space was allocated for a reception room for mothers interested
in donating or needing lactation support. Facility requirements were
established in alignment with local food safety guidelines for food
production and business facilities. Multiple international human milk
banking experts guided the HMB team and provided feedback based on their
experiences. The DNHWC facilities’ director, along with members of the HMB
team, supervised the construction of the HMB facility. For the procurement
of necessary equipment and supplies, the Project Advisory Committee and HMB
team, facilitated by PATH and Alive & Thrive, determined the optimal
equipment and imported it. Licenses were obtained and the equipment was
properly installed. Lacking reliable domestic suppliers, the human milk
automated pasteurizer, containers for pasteurization, freezers, and laminar
hood flow cabinet were imported. International equipment manufacturers
provided guidance on the maintenance needs of the equipment, to be monitored
locally.
Hazard Analysis and Critical Control Point (HACCP) Training to Inform
Standard Operating Procedures (SOPs)
PATH, with support from a local certified quality control consultant, trained
the multidisciplinary HMB team on the HACCP process, a quality assurance
planning process for food systems, adapted to the HMB context (Arslanoglu et al.,
2010; Hartmann, 2017; PATH, 2013, 2016). The HACCP workshop and
information from the learning exchange led to a final HACCP plan, which
served as a best practice for determining locally appropriate procedures,
and revealed gaps where systems strengthening would be required for optimal
quality and safety.
Development of Guidelines, SOPs, and Training Materials
Incorporating learnings from guidelines from other countries, the HMB team,
with the support from the Project Advisory Committee, developed key
guidelines and SOPs as a part of the process to ensure consistency and
safety in practice (Centre for Clinical Practice at NICE, 2010; Human Milk Banking
Association of North America, 2011, 2018; Philippines Department of Health,
2011). Every step in the HMB process (Figure 2) was detailed in three
manuals of operation and 22 SOPs. The manuals and SOPs cover various
components of HMB practices, including donor recruitment, donor screening,
milk expression and handling, storage, pasteurization, microbial testing,
and the distribution of PDHM to the neonatal unit (Table 2). Training materials were
developed, targeting nursing staff from the newborn care and postnatal
wards, nutrition and lactation support staff, microbiologists, and infection
control and quality assurance staff, along with key leadership across
hospital departments.
Figure 2
Operation Diagram of the Human Milk Bank at Danang Hospital for Women
and Children. Note. This diagram explains the
process that donor human milk follows throughout the human milk bank
pathway from donor to recipient to maintain safety and quality. DHM
= donor human milk; microbio. = microbiological; pasteur. =
pasteurization; PDHM = pasteurized donor human milk.
Table 2
List of Manuals of Operation and Standard Operating Procedures.
Manuals and
Procedures
Location
Where Applied
HMB
NU
PW
QA
Manuals of operation
(MOP)
Donor recruitment
√
√
√
Donor education
√
√
√
Feeding the recipient
√
√
Standard operating procedures
(SOP)
Developing and approving a
SOP
√
√
√
√
Regulations on recording
documentation of donor milk
√
√
√
Regulations on labeling donor
milk
√
HMB donor screening
√
HMB donor selection and
approval
√
Hand washing and HMB staff’s
health status condition
√
Sending containers to HMB
donor
√
Milk storing
√
√
√
Transport of donor milk
√
Pasteurization
√
Donor milk screening
√
Donor milk testing
√
Estimating need and ordering
DHM
√
√
Recipient prioritization and
consent
√
√
Defrosting, aliquoting
√
Washing of HMB containers and
tools
√
Periodic maintenance of HMB
facility and equipment
√
Cleaning HMB facilities
√
Internal monitoring and
supervision
√
Detecting deviation and
implementing corrective actions
√
Pasteurizer operation and
maintenance
√
Training staff working on HMB
related tasks
√
Note. HMB = human milk bank; MOP = Manuals of
operation; NU = Neonatal Unit/ Neonatal Intensive Care Unit; PW
= Postnatal Ward; QA = Quality Assurance Unit; SOP = Standard
operating procedures.
Training and Coaching on HMB-Related Topics
Most hospital staff, including all of those with a role in feeding neonates,
were trained on HMB-related topics (e.g., donor recruitment and donor
education; breastfeeding counseling and support; safe collection, handling
and transporting of raw DHM; pasteurization process at the HMB; and
indications and appropriate use of PDHM). In addition, HMB staff were
provided with comprehensive training about the pasteurization process,
taking samples of raw and pasteurized DHM for microbiological testing, and
the use of the digital information system for tracking processes from donor
recruitment to the use of PDHM.
Digital Information System to Optimize Operations
A digitized HMB monitoring system was developed to align with the guidelines
and SOPs. It provided real-time data to (1) optimize the operation of the
HMB; (2) ensure that all HMB activities follow standardized protocols; and
(3) serve as a track and trace system for PDHM. The track and trace system
included demand generation, donor management, milk processing, milk
distribution, recipient management, PDHM usage, container tracking, and
reporting. The electronic system helped to reduce paper-based monitoring
forms, except those needed for legal status (e.g., informed consent,
pasteurization procedure, testing results, and approval of PDHM use). This
system also assisted milk tracking and tracing based on donor identification
barcodes and container barcodes, facilitating rapid track and trace
capability in the potential event of a recall of PDHM. The real-time data
automatically generated reports and charts.
Baseline–Endline Feeding Assessments
Baseline and endline assessments were performed to determine the changes in
feeding behaviors, and knowledge, attitudes, and practices of mother-baby
dyads in the neonatal and post-natal departments at DNHWC before and 8
months after the launching of the HMB. Results will be presented in a
subsequent manuscript.
Ensuring Sustainability: A Costing Assessment
A costing assessment performed by a team from Hanoi University of Public
Health reviewed start up and recurring costing data from secondary sources,
including financial reports and observations, and interviews to estimate the
costs of PDHM and for sustaining the HMB. Publication of the findings of the
costing study are underway.
Operation and Stabilization (February 2017–April 2019)
The HMB officially launched in February 2017, marked by the collection,
processing and storing, and allocation of PDHM to the neonatal unit. An official
opening ceremony was held with a high level of visibility to showcase the
importance of an HMB in saving newborn lives throughout Vietnam. Demand
generation activities were subsequently conducted through events, one-on-one
engagements, mass media, and social networking to advocate for the use of PDHM,
the recruitment of donors, and the promotion of breastfeeding.
The HMB integrated into associated hospital services—neonatal and postnatal care,
and lactation support activities—and improved the access to and intake of human
milk for infants cared for at the DNHWC. During the 2 years of implementation
(from February 2017 to April 2019), 755 mothers were approached for donor
recruitment. Of these, 397 agreed to become donors; 314 of these passed
screening tests and were trained with needed skills for safe donation, and
subsequently donated milk to the HMB (Table 3). The donors had a mean age of
28 years; 60% resided in Danang City, 80% gave birth at DNHWC, and 50% donated
during their child’s admission (Table 3). In total, the HMB collected
4,400 L of donor milk (Table 4). During the first 6 months of operation, 60% of the
donations passed pre- and post-pasteurization screening, which later increased
to approximately 80% in 2018. The total PDHM provided to the neonatal and
postnatal wards during the first year of operation was 3,139 liters, of which
65% was administered within the neonatal unit (Table 4). The HMB served 8,071
vulnerable infants (~35% in the neonatal unit), who would otherwise have
received human milk substitutes as mother’s own milk was insufficient or not
available (Table 5).
Average duration for the use of PDHM in the neonatal unit and postnatal ward was
4 days and 1 day, respectively (Table 5).
Table 3
Recruiting, Screening, and Managing Donor Mothers at the Human Milk Bank
at Danang Hospital for Women and Children.
Activities
Location
N
In Hospital
n (%)
Out of Hospital
a
n (%)
Group counseling sessions for
demand generation (≤ 10 mothers)
33
33 (100)
0 (0)
Demand generation events (> 10
mothers)
7
7 (100)
0 (0)
Lactating mothers who attended
donor recruitment (total):
762
579 (76)
183 (24)
One-on-one
570
387 (67.9)
183 (32.1)
Group
185
185 (100)
0 (0)
Mothers who expressed interest in
donating after recruitment
397
270 (68)
127 (32)
Mothers screened
321
164 (51.1)
157 (48.9)
Lactating mothers screened and who
met all requirements to be donors
324
166 (51.2)
158 (48.8)
Eligible human milk donors taught
proper hygiene and donation skills
b
321
164 (51.1)
157 (48.9)
New donors
314
156 (49.7)
158 (50.3)
Note. Reporting period is February 2017–April 2019.
Data presented as value (row percentage of the total).
aIncluding donors who were hospital staff who typically
expressed milk at home but occasionally in the hospital.
bSkills include proper hand washing; safe expression
of milk; and how to store, label, and safely handle donor human
milk.
Table 4
Volume of Donor Milk Received and Pasteurized at the Human Milk Bank at
Danang Hospital for Women and Children.
Location
Total Volume
In Hospital Volume (%)
Out of Hospital
a
Volume (%)
Volume of milk donated (L)
4401
1301 (29.6)
3100 (70.4)
Volume of pasteurized donor milk
(PDHM; L)
4173
1268 (30.4)
2906 (69.6)
Passed pre-pasteurization test
(L)
1995
722 (36.2)
1273 (63.8)
Passed post-pasteurization test
(L)
2869
711 (24.8)
2158 (75.2)
Volume of donor milk disposed
(L)
727
332 (45.7)
395 (54.3)
Volume of PDHM at the HMB at the
time of reporting (L)
1033
437 (42.3)
596 (57.7)
Note. Reporting period is February 2017–April 2019.
HMB = human milk bank; PDHM = pasteurized donor human milk. Data
presented as value (row percentage of the total).
aIncluding donor milk from hospital staff who expressed
milk at home and occasionally in the hospital.
Table 5
The Performance Indicators (Use of Pasteurized Donor Human Milk) Grouped
by Location.
Performance
Indicators
Location
N
Unit, n
(%)
Postnatal and Postoperative
Unit, n (%)
Volume of distributed PDHM
(L)
3139
2035 (64.8)
1104 (35.2)
Number of newborns who used PDHM
from HMB
8071
2784 (34.5)
5286 (65.5)
Volume of PDHM distributed to
infants (L)
3042
1968 (64.7)
1074 (35.3)
Average number of days using PDHM (days)
a
03
04
01
Note. Reporting period is February 2017–April 2019.
HMB = human milk bank; PDHM = pasteurized donor human milk. Data
presented as value (row percentage of the total). a Among
those who stopped receiving PDHM during the reporting period.
Lactation support was strengthened for all mothers at the hospital by training
hospital staff for improved breastfeeding, milk expression, and milk storage
practices. Additionally, the availability of the HMB services and access to the
HMB facility created additional touch points for lactation support. Overall
strengthening of lactation support included key messages for early and frequent
breastfeeding or milk expression, promoting the mother to visit and be present
as often as possible, the use of mother’s own milk when possible, and the use
and cleaning of breast pump parts (when appropriate). Having PDHM from the HMB
improved the safety of alternative feeding practices, when compared to
unmonitored sharing of maternal milk on the neonatal unit, a practice that is
not common everywhere and in which global frequency is not well tracked or
understood. Other benefits included: improved breast pump cleaning practices,
availability of refrigeration for human milk storage, staff training on
lactation support, and consistency and precision in recording newborn feeding
practices in the neonatal unit.
Continued Quality Improvement
Quality control assessment systems were implemented, using the HACCP protocol
and rigorous SOPs. Audit systems were developed for the HMB internal quality
assurance team to implement on a quarterly basis. Ongoing quality assurance
visits were enacted both by hospital-based teams, project-level teams, and
international HMB experts. Quality control visits from PATH and Alive &
Thrive were conducted through visits from local project staff and
international support. In addition, an international HMB expert from
Scotland provided technical assistance on-site for evaluating the use of
PDHM and the safety of the HMB processes and strengthening training for
breastfeeding and lactation support for mothers with vulnerable infants.
The internal quality assurance team for the HMB included clinical staff
representatives from various hospital departments, including neonatal care,
and postnatal care, lab and infection control departments, hospital quality
control and nursing management units, and the HMB operations staff. Internal
auditing for safety and quality HMB integration included: compliance review
of the HMB guidelines, maintenance and functionality of the equipment,
hygiene and safety of the HMB facility, and staff performance.
Challenges Faced in Implementation
Challenges faced in the implementation process of the DNHWC’s HMB system for optimal
newborn nutrition included the financial and time costs of doing the intervention
for the first time in a country, without access to ongoing technical monitoring and
support structures or examples in the proximal area. Additionally, the lack of
global guidelines for establishing and operating HMBs and the critical need for
procedures to be contextually driven made it difficult to create a streamlined
approach. The resources required are extensive; however, it does have potential,
future cost-saving opportunities due to the improved health outcomes associated with
the use of PDHM (Ganapathy et
al., 2012; Mahon et
al., 2016; Trang et
al., 2018). Ongoing costs for HMB operations continue to be challenging
at this site. However, they are not beyond what the hospital is able to commit to,
and leadership has indicated support for ongoing ownership.
Expansion of Model and Sharing Results (May 2017 to date)
In Vietnam and Southeast Asia
The Danang model has the potential for success in improving neonatal
nutrition in other regions within Vietnam. For effective replication of this
model to serve multiple regions in Vietnam, a minimum of two to three
additional HMBs integrated into facilities have been proposed by the MoH. A
regional-based model where the HMB supplied to hospitals serving sick and
vulnerable newborns in the region is being developed. The concept is to
strengthen the essential programs for lactation support, breastfeeding
promotion, and PDHM collection and distribution in the satellite hospitals.
Optimal scale-up will require human milk donations to be accepted from
external facilities to the hospital, requiring cold-chain systems for safe
transportation.
Other settings, including Glasgow, Scotland, have employed this national HMB
model successfully to serve all the neonatal care sites in the nation, and
hold promise as examples for Vietnam’s success. The MoH has indicated the
potential for expansion to hospitals in northern and southern Vietnam. DNHWC
is already mentoring future HMBs in Vietnam and across the Southeast Asia
region, supported by policy leaders’ strong ongoing commitment and
recognition of this HMB as a center of excellence. To date, the DNHWC HMB
has hosted five knowledge exchange visits from hospital leadership in
Vietnam, China, Indonesia, and Myanmar. The HMB staff has also provided
technical assistance to other hospitals in Vietnam and in Southeast Asia.
The second HMB in Vietnam recently opened in April 2019, at Tu Du Hospital
in Ho Chi Minh City, the largest maternity hospital in Vietnam with 70,000
births each year. As a regional leader, Vietnam serves as a model for
improving health systems to support all infants to receive human milk as the
primary diet, prioritizing mother’s own milk for her own infant, and
providing PDHM for the most vulnerable neonates in need.
Global Linkages
The experience of establishing a HMB within the DNHWC context is not unique;
other LMIC HMB programs share similar challenges in safety, quality, and the
availability of functional support systems (i.e., access to lab facilities,
cold chain transportation, and the provision of trained lactation support
for all mothers). This first HMB in Vietnam can serve as an example for
integrating services and improving neonatal nutrition programs globally. The
Vietnam experience was one of many country experiences that informed the
development of the Resource Toolkit for Establishing and Integrating Human
Milk Bank Programs—A Global Implementation Framework (PATH, 2019a).
Conclusion
The successful integration of a HMB into the existing health system at DNHWC for
improved maternal lactation support and infant feeding practices provides an
exemplary model for other hospitals caring for sick and vulnerable newborns in
Vietnam, the broader Southeast Asia region, and globally. Several enabling factors
and essential program components from this experience are adaptable and applicable
to settings seeking to implement new HMB systems or improve existing systems.
Utilizing technical expertise from HMB experts globally ensured Vietnam’s first HMB
was not built in isolation, but instead built upon over 100 years of international
learning in the processing and provision of PDHM through HMBs. Especially in the
absence of global guidance and WHO recommendations, learning from experiences
globally is vital for the success of future programs. Aligned nutrition and newborn
policies at global and regional levels, as well as global guidance, standards, and
a
network for sharing best practices are needed to improve the safe, quality, and
appropriate provision of PDHM to infants in need. A comprehensive approach to
integrate HMB systems within newborn and nutrition programming can ensure all
infants have equitable access to human milk. Successful implementation of an
integrated HMB model in a country or region will help to protect, promote, and
support breastfeeding practices which, in turn, will help to reduce infant deaths,
especially for the small and sick newborns.