Un progetto di tirocinio clinico responsabilizzante per un Cdl Amico dell’Allattamento

Background: The WHO and UNICEF have implemented programs for Hospitals & Children's Friends Communities. This initiative provides for the protection, promotion and support of breastfeeding and the parent-child relationship through collaboration with health, social and public health services to improve care at birth points, counseling centers, nursery schools and degree courses who train professionals who will work with pregnant women and families. The degree course of Midwifery of the University of Milan in 2017 was recognized as a graduation course “friend of breastfeeding”. The benefits of breastfeeding for both mother and baby are now well known. Breast milk protects against childhood infections and malocclusion, increases intelligence and probably reduces the incidence of overweight and diabetes, for breastfeeding women, breastfeeding provides protection against breast cancer and has improved time that passes between one birth and another and could also protect against ovarian cancer and type 2 diabetes (Cesar G. Victora, 2016). In low and middle income countries, only 37% of children under 6 months are exclusively breastfed. With few exceptions, the duration of breastfeeding is shorter in high-income countries than in those that are resource-poor (Cesar G. Victora, 2016). In 2003, the World Health Organization (WHO) recommended that children should be fed exclusively with breast milk up to the age of six months (Marlies Swerts, 2016). In high-income countries, less than one child in five is breastfed at the age of 12 months (Cesar G. Victora, 2016) The protection, promotion and support of breastfeeding is also essential for achieving many of the sustainable development goals recently launched by 2030 (Cesar G. Victora, 2016). The crucial period for breastfeeding support is the first two weeks after birth (Marlies Swerts, 2016). During this time, support for midwife breastfeeding is required. The latest report on the state of Midwifery in the world confirms the crucial role of midwives as key professional figures in maternal / neonatal care (Guidelines for the definition and organization of autonomous midwifery care for low pregnancies obstetric risk (BRO), Ministry of Health, 2017).There are several scientific evidences regarding the fact that theoretical teachings together with practical ones can improve students' knowledge and behavior regarding breastfeeding (Shu Fei Yang, 2019). The importance of surgeryal practice is highlighted in order to ensure that midwives are prepared to provide an autonomous and woman-centered care (Andrea Gilkison, 2015). The successful obstetric model is supported by three pillars: education, practice and autonomy; produces competent and confident midwives capable of working under their own responsibility (Andrea Gilkison, 2015). Aim: put into practice by the students what has been learned in the classroom and put them in a situation of responsibility and autonomy, while still maintaining a "protected" environment. As the Degree Course in Obstetrics of the State University of Milan is recognized as “Friend of breastfeeding”, this experience was carried out at the puerperium surgery; an important occasion for the promotion and support of this theme. Collecting data during this journey has allowed us to understand the quantity and type of women who turn to this service and to understand how to improve the service offered to them. Design: a retrospective cohort study Methods: 25 graduate students and 6 obstetrics (3 of them IBCLC) were involved. Students managed the puerperium surgery of the Mangiagalli Surgery, at the IRCCS Cà Granda Foundation, Maggiore Policlinico Hospital, from 17 June 2019 to 4 October 2019 in outpatient hours from 09.00 AM to 01.30 PM. The data were stories through an Excel database that records the activities during the hours of the surgery and at the end of the service, the reference obstetric tutor / coordinator, together with the students in turn evaluated the morning case management, to late morning or at the agreed time. At the beginning of the project, each student had a document containing the name and contact details of the reference midwife to contact in case of need. For two weeks the reference midwife was always present with the students to verify the feasibility of the project Findings: only 29.7% of women in laboratories have entered the clinic, the results show that the puerperium surgery is actually used by women mainly for the removal of stitches. In fact, 84.82% of women entering the puerperium surgery had a cesarean section. Only 11.52% of women go to the clinic asking for breastfeeding support. 63.03% of women have exclusive breastfeeding and comparing primiparas to multiparas we can see a greater incidence of complementary breastfeeding in primiparas. In 91.22% of women with exclusive or complementary breastfeeding this is autonomous. Relating exclusive breastfeeding to the mode of childbirth it is clear that women who have had a vaginal birth have higher rates of exclusive breastfeeding. More specifically analyzing multiparous women we can note that 50.82% of women who had had a vaginal birth in eutocy in the previous pregnancy, in the current pregnancy have chosen to make an elective cesarean section. Instead, data regarding breastfeeding between the previous pregnancy and the current pregnancy remain mostly unchanged. There was no need to send women to the emergency room or the territory in 97.07% of cases and the reference midwife was called only in 2.69% of cases. Conclusions: the presence of a puerperium surgery is an important element for the support and promotion of breastfeeding and to be able to stay close to women during this period of their life, for this reason the service should be increased and improved. Currently the clinic is considered mainly by women for the removal of stitches. There are few women who turn to this service for other problems typical of the puerperium. The results also show that a vaginal delivery can positively influence breastfeeding. Regarding the experience of clinical practice of students, they have managed most of the cases independently. Renewing the services offered by this clinic could be a starting point for increasing exclusive breastfeeding rates. Relevance to clinical practice: Talking much more about puerperium and especially about breastfeeding during birthing class, making particular meetings about it. The puerperium surgery could be promoted much more. It could become a reference point for women during the 40 days after giving birth. Organizing afternoon meetings could be a valid initiative to struggle the loneliness during puerperium and to support women during the breastfeeding staying close to them. Not involving only women but also fathers could be a valid method for family composure and so a positive environment for the breastfeeding.