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Improving practical skills for breastfeeding vulnerable infants in low resource settings: A case study from Rwanda

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By Himali de Silva and Maya Asir, with contributions from Kathryn Beck, Catherine M Kirk, Gato Saidath, Marie Louise Manirakiza and Egide Karangwa

Himali de Silva is a speech and language therapist working for the National Health Service (NHS) in the UK, where she works as a clinical specialist in infant feeding. She has worked in several countries providing training to healthcare professionals.

Maya Asir is a speech and language therapist working for the NHS in the UK, where she works as a clinical specialist in infant feeding in a hospital setting. She has worked in several countries providing training to health professionals.

Kathryn Beck is the Senior Nutrition Program Manager at Partners In Health/Inshuti Mu Buzima, Rwanda.

Catherine M Kirk is the Director of Maternal and Child Health at Partners In Health/Inshuti Mu Buzima, Rwanda.

Gato Saidath is a Maternal and Child Health Program Officer at Partners In Health/Inshuti Mu Buzima, Rwanda.

Marie Louise Manirakiza is a registered nurse and Mental Health Program Manager at Partners In Health/Inshuti Mu Buzima, Rwanda.

Egide Karangwa is a Maternal and Child Health Program Officer at Partners In Health/
Inshuti Mu Buzima, Rwanda.

A significant proportion of premature infants and infants with birth asphyxia and congenital anomalies who may appear to be able to feed using generic intervention strategies are unable to coordinate sucking, swallowing and breathing required for safe feeding. Without specific intervention strategies to minimise risks, these infants can go on to develop lower respiratory tract infections from aspirated material and malnutrition. Informed by a review of existing materials, the Working with Infants with Feeding Difficulties (WIFD) training package was developed to fill an identified gap in training content on feeding issues among such infants for frontline healthcare staff of neonatal intensive care and special-care baby units in low-resource settings (De Silva and Asir, 2017). WIFD focuses on timely identification and intervention to prevent deterioration of feeding and can be delivered as a standalone training or integrated into other relevant training programmes. The package is currently delivered by two course directors employed by Multi Agency International Training and Support (MAITS)1 and consists of four hours of interactive, classroom-based training and five hours of practical work with guided observations, hands-on training and clinical discussions, usually delivered over two days. A five-to-six-day Training of Trainer course is also offered to train ‘Master Trainers’ to train, guide and supervise other health workers in their country and region, with continued support from the course directors. WIFD has so far been trialled in Malawi, Uganda, Sri Lanka and Rwanda across nine hospitals. A total of 175 healthcare staff have received training to date, including three Master Trainers.

Rwanda case study

WIFD was delivered to 21 health workers in Rwanda in February 2018 through a partnership between Partners in Health (PIH) and MAITS. The practical sessions were delivered in the neonatal care, post-partum, caesarean section and maternity units of Rwinkwavu District Hospital, a government hospital located in the eastern province of Rwanda. Three Master Trainers were trained by the course directors, selected on the basis of their backgrounds as nutritionists, nurses and midwives and desire to share knowledge and skills with others. Pre- and post-test evaluations demonstrated a self-reported rise in trainees’ confidence, knowledge and practical skills in this topic (average pre-test score 54% and average post-test score 90%). Significant improvements were seen after the WFID training (March-July 2018) compared to the pre-training period (October 2017-February 2018) in the initial two hospitals where training was conducted: breastfeeding on the day of birth increased from 11.3% (n=37/237) to 26.9% (n=111/413, p<0.001); delayed introduction of breastmilk until two days or later after birth reduced from 49.6% (n=235/474) to 36.2% (n=193/533, p<0.001); and exclusive feeding from the breast at discharge increased from 63.1% (n=279/442) to 75.9% (n=441/581, p<0.001). There were non-significant trends of decline in neonatal unit mortality from 11.0% (n=61/493) of admissions to 8.1% (n=51/593, p=0.092) and no change in length of stay (mean of 10.4 days pre-training (n=554) and 10.5 days post-training (n=645, p=0.134) in the period immediately after training.2

Since the original training, two additional Master Trainers have been trained by the Master Trainers in Rwanda, with remote support from the course directors, and the Master Trainers have gone on to train an additional 70 health providers working across 10 district hospitals in all five provinces of Rwanda, reaching more than 4,400 mothers and babies. To ensure sustainability and consistent support for mothers in neonatal and post-partum units, a new hospital-based position of ‘Expert Mother’ was created. This position is now functioning in all three PIH-supported district hospitals in Rwanda, with two Expert Mothers per hospital. Expert Mothers are women who previously had a child on the neonatology unit and have received training and mentoring from Master Trainers to provide breastfeeding peer counselling to other mothers through mentorship, teaching and peer support.

Next steps

The Master Trainers in Rwanda will continue to provide mentorship to hospital neonatology and maternity unit-based staff, as well as the six Expert Mothers who have been trained with ongoing support from the course directors. There is also potential to use these Master Trainers to train other Master Trainers in other countries in the same region. PIH plans to continue to monitor the impact of the WIFD training, including the Expert Mothers intervention, and seek opportunities to expand the reach of the Master Trainers, both within Rwanda and in other countries. Currently, the Master Trainers are leading ongoing research assessing the effectiveness of the breastfeeding interventions, including the WIFD training and the Expert Mothers. Further evaluation of the impact of the training on health outcomes for infants is required, as well as investigation into caregiver views on support received pre- and post-training. Opportunities are also being investigated to integrate WIFD into the World Health Organization kangaroo mother care training, which is well established in Rwanda, to enable more facilities to access the training.

For more information please contact Himali de Silva and Maya Asir.


1MAITS is a charity that aims to improve access to healthcare and education for people with disabilities through training.

2Impact on length of stay and mortality of the training and other interventions is being examined to feature in future peer review publication (and Field Exchange summary).


De Silva, H & Asir, M (2017) Working with infants with feeding difficulties: a training programme for healthcare staff in low-resource setting, MAITS, UK

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Reference this page

Himali de Silva and Maya Asir, with contributions from Kathryn Beck, Catherine M Kirk, Gato Saidath, Marie Louise Manirakiza and Egide Karangwa (). Improving practical skills for breastfeeding vulnerable infants in low resource settings: A case study from Rwanda. Field Exchange 61, November 2019. p7.



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