1. Indonesia: Lesson Learn from 4 in 1 Training and Planning Ahead
Farahdibha Tenrilemba S.S., M.Kes.
Secretary General AIMI Indonesia Breastfeeding Mother Association
2nd World Breastfeeding Conference
Johannesburg, Dec 13, 2016

2. Farahdibha Tenrilemba S.S., M.Kes ww.farahdibhatenrilemba.org
Breastfeeding Mother
Secretary General of Indonesia Breastfeeding Mother Association
Lecturer at Faculty of Heatlh of Universitas Respati Indonesia (URINDO)
National Trainer for 4in1 training/course Module IBFAN/BPNI
Facilitator for 40-hour WHO/UNICEF Training
Breastfeeding Counselor
Complementary Feeding Counselor
Facilitator for Breast Massage Arugaan Filipina Module

3. Acknowledgement Director: Dr. Prof. KP Kushwaha, M.D., FIAP
National Trainers
Astri Pramarini, dr, IBCLC
Aswita Amir, DCN, M.Si
Elsi Ermalinda, S.Si.T
Frecillia Regina, dr., SpA, IBCLC
Preparation Team
Angky Patria Ruswinda, ST
Astrid Romilda Hantari, S.Si
Elyca Rahmawiyanti, S.Kom
Nurfadilah Irianty, ST
Counseling Specialists
AIMI Headquarter and AIMI East Java Branch
Hospitals in Sidoardjo as clinical practice based

4. Current Situation Under nutrition below 2 yrs
Development and growth below 2 yrs
Importance of breastfeeding
Importance of complementary feeding
Growth monitoring and early detection of growth faltering
Artificial feeding and early child morbidly, growth, development and mortality
Marketing of formula and international code
HIV and infant feeding challenge

5. The 4 in 1 Training an integrated Course on Breastfeeding, Complementary feeding, Infant Feeding & HIV and Growth Monitoring Counseling
This course has been in used for 12 years in India and many Asian countries. Training has been found very effective and countries like Afganistan, Nepal have started trainings in the country using their own trainers trained.

6. 4 in 1 Training in Indonesia
AIMI and BPNI/IBFAN jointly organized the training course to develop National Trainers (NT) in IYCF counseling and IYCF Counseling Specialists (CS) for Indonesia.
Objective
makes counseling specialists competent to support infant and child feeding in various situation.
for the NT to lead training courses in Indonesia independently.
Methodology -- Divided into 2 parts:
TOT for 6 days by Prof (DR.) K.P. Kushwaha as course director, comprises of training skills, knowledge on IYCF and counseling skills. Which later be NT
4 in 1 training for 7 days (47 sessions) under constant supervision of CD which later be certified counseling specialists.
This course is based on counseling.
Demonstration session on various counseling skills
Clinical practice sessions
Written exercises for every skill

7. Arrangements
3 hospitals for clinical practice : Sidoarjo Hospital – public hospital, Siti Hajar – private hospital, Pusdik – military hospital
In Sidoarjo and Siti Hajar hospitals there are labour rooms, obstetric ward, pediatrics ward, pediatric OPD, immunization center, neonatal ward, and neonatal intensive unit. In Pusdik there are labour rooms and obstetric ward.
There are 5 trainers trained in TOT : Astri Pramarini, dr, IBCLC, Aswita Amir, DCN, M.Si, Elsi Ermalinda, S.Si.T, Frecilia Regina, dr, Sp.A, IBCLC, Farahdibha Tenrilemba, SS, M.Kes
There are 19 participants. They included pediatricians, general doctors, dentist, midwives, psychologists, AIMI Counselors and even an architect. They were very interactive and attentive in the class.

8. Outcome
During the TOT, all different types of sessions were alloted to all trainees, so they can learn the presentation sessions, demonstration of clinical skills, demonstration of counseling skills, group work, facilitating a written exercise, and leading a clinical practice , which is very usefull.
Suggested to include Indonesian mother’s pictures in course material for counseling sessions. For trainees, it was good experience and they could learn skills of trainers and skills of counseling skill very well.
During clinical practice, (on an average) newborn in obstetric ward, children less than 2 years in pediatric OPD, children in pediatric ward, 4-5 babies in NICU, 10 newborns in neonatal ward
In all hospitals newborns are separated from mothers just after birth and kept in neonatal ward.
Children attending OPD and admitted in ward are mostly bottle feed/formula feed. Use of Soya formula and low lactose formula are used in children who are bottle feed and have diarrhea.

9. Outcome
The evaluation of participant done using Clinical Competency Assesment Questionnaire.
From the assessment,
All 19 participants were able to recognize and help mothers with breast conditions.
Out of 19, 15 have experience of helping mothers of sore nipples, and other helping mothers with engorment.
All participants were able to mention feeding options in HIV positive mothers and were able to counsel and support mothers in safe breastfeeding options.
Seven of them have difficulties in helping mothers in positioning and attachment, and helping mother in different position and breastfeeding.
Some participants (7) have difficulty in seeing babies with refusal to breastfeed and helping them. They also did not see the relactation.
Only 2 participants could not identify good and poor attachments, and could not use the skill of listening and learning well, though all of them know and use few skills of listening and learning.
All except 1 were able to learn taking feeding-history, growth monitoring and expression of breastmilk.
Two participants have difficulty in counseling babies for complementary feeding. Three participants could not assess hospitals weather they are honoring International Code of Marketing of Breastmilk Substitute.
Five participants have required most of the skills of counseling in various breastfeeding and complementary feeding situations and in future if they wished they can be taken as trainer after repeating the complete course.
All participants are able to counsel mothers in breastfeeding, complementary feeding, HIV and growth monitoring.

10. Take Home Notes
Many participants suggested to have longer and more supervised clinical practice session. They need all training material and training to be conducted in Bahasa.
For some few demonstration sessions were short. They want to learn hand on experiences on positioning and expression more both in class and clinics.
One participant suggested the classroom need to be more comfortable.
Most of them found it to enhance their capacity and knowledge.
One participant suggested to include one chapter in difficulties faced by counselors.
Participants Commitments: to work as counselors in infant and child feeding. During training we provided box for suggestion to improve course. The training was improved based on their suggestions.
Most of AIMI have shown their commitments to work with mothers and babies in the community in different provinces, as well as make school education support to IYCF. Moreover, advcocacy work with government to protect breastfeeding by adequate legislation, especially for working mothers by making more supportive workplaces for breastfeeding
Health workers attended this training to create mother to mother support in hospitals and to allocate room for breastfeeding in hospital. Also, change hospital practices to baby friendly and develop IYCF counseling center in their facilities

11. Programming
Programming the 4 in 1 course for training of concerned workers at all levels of contacts with mothers and baby
Institutions
Maternity hospitals
Neonatal and PEDIATRIC hospitals
Health centres
Community

12. Planning Ahead Preparing more National trainers
The certified National Trainer need to organize training courses in all provinces for community health workers and nutritionists, since there are still lot of hospitals feed baby with formula
Infant and child feeding counseling is urgently needed in hospitals and community, therefore
Developing trainers of family counselors and facility based counselors (middle level trainers)
Training of family counselors IYCF
Work together with government to improve IYCF status in the country by assigning counseling specialist specific responsibility
National Trainers are capable in doing training for doctors and health providers, later on advocate for Making hospitals baby friendly ( BFHI)
AIMI as organization with skilled trainers and counseling specialists and should be utilized in the country for IYCF training and counseling and monitoring of CODE, therefore
Developing training centres
Creating network of community IYCF councelors
Training of Counselors of PPT centre for IYCF counseling
Monitoring and evaluating training programme

13. THANK YOU