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Croat Med J. 2010 Oct;51(5):396-405.

Effectiveness of the UNICEF/WHO 20-hour course in improving health professionals' knowledge, practices, and attitudes to breastfeeding: before/after study of 5 maternity facilities in Croatia.

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Department of Family Medicine, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia.



To evaluate knowledge, practices, and attitudes to breastfeeding among Croatian health professionals before and after the United Nations International Children's Emergency Fund/World Health Organization (UNICEF/WHO) 20-hour course.


Study included 5 of 9 maternity hospitals in southern Croatia, which had completed the UNICEF/WHO 20-hour breastfeeding training course between December 2007 and February 2009. An anonymous questionnaire testing knowledge and practices, and attitudes was distributed to 424 health professionals before training and to 308 health professionals afterwards. Health professionals' attitudes were assessed using the validated Iowa Infant Feeding Attitude Scale.


The pre-training response rate was >90%, but only 53% of data were analyzed; the post-training response rate was 69%. Only one-fifth of health professionals prior to training knew that breast preparation in pregnancy was unnecessary, but this increased to 57% after training (P<0.001). The proportion of health professionals who recognized hospital practices that support breastfeeding and signs of poor positioning when breastfeeding nearly doubled after training (P<0.001). The proportion of health professionals correctly recommending immediate "skin-to-skin" contact post-Cesarean section under local anesthesia did not improve significantly, and stratification analyses showed that younger respondents (<36 years) were more likely to support this practice. Although the proportion of health professionals who correctly managed mastitis improved significantly as a result of the training, the proportion of those who after training inappropriately recommended partial or complete cessation of breastfeeding remained high at 47%. The number of staff with positive attitudes toward breastfeeding increased from 65% to 79%, whereas the number of staff with neutral attitudes dropped from 26.6% to 9.9% (P<0.001). Even after training, a substantial proportion of health professionals showed uncertainty in their attitude toward alcohol consumption and breastfeeding.


The UNICEF/WHO 20-hour course appears to be an effective tool for improving health professionals' breastfeeding knowledge, attitudes, and practices.

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