Global implications of the new WHO and UNICEF implementation guidance on the revised Baby‐Friendly Hospital Initiative

Abstract

Although breastfeeding confers both short‐ and long‐term benefits for children and their mothers, breastfeeding practice remains suboptimal, globally. In addition to barriers including misperceptions and inappropriate marketing of breast milk substitutes, inadequate support for breastfeeding remains a challenge in many settings. To improve access to appropriate health system support, the World Health Organization (WHO) has reviewed the Baby‐Friendly Hospital Initiative (BFHI), which ensures provision of optimal clinical care and support to mothers and their infants. This review has resulted in revision of the Ten Steps to Successful Breastfeeding, which form the core standards of (BFHI). These now consist of critical management procedures to support breastfeeding (Steps 1 and 2) and key clinical practices to support breastfeeding (Steps 3‐10). In Step 1, there is now specific emphasis on compliance with the WHO Code of Marketing of Breast‐milk Substitutes and relevant World Health Assembly resolutions as well as on internal monitoring. There are also significant position shifts like the recommendation to “Counsel mothers on the use and risks of feeding bottles, teats, and pacifiers,” which is a departure from the earlier position of avoiding reference to these technologies. These revisions require countries and states to revise activities and tools for their local situation but without compromising the standards.

1. INTRODUCTION

Breastfeeding is a biological norm for feeding young children. When practiced appropriately, it confers a myriad of health and other human development benefits on the child, the mother, and the society as a whole. Recent evidence has demonstrated that increasing rates of breastfeeding could generate about 300 billion dollars each year for the global economy. Further, scaling up optimal breastfeeding practices could prevent more than 800,000 deaths in children per year. Breastfeeding also has benefits for the breastfeeding mother. A key outcome of appropriate breastfeeding is reduced risk of future‐onset noncommunicable diseases. For example, increasing and improving breastfeeding practices can reduce about 20,000 deaths per year from breast cancer (Rollins et al., 2016; Victora et al., 2016).

The World Health Organization (WHO) recommends exclusive breastfeeding for the first 6 months of an infant's life, with continued breastfeeding up to 2 years of age or beyond, along with nutritionally adequate, safe, and appropriate complementary foods (WHO, 2003). However, breastfeeding practice is increasingly under threat of being rolled back due to cultural change, aggressive marketing of breast‐milk substitutes, and inadequate support from the health system, families, communities, and the workplace (Rollins et al., 2016). Mothers and their families, therefore, need guidance and support that will enable them to successfully initiate and sustain appropriate breastfeeding. This support should be underpinned by appropriate evidence‐based standards and capacity.

2. HEALTH SYSTEM SUPPORT FOR BREASTFEEDING

In 1989, in an effort to reverse the global trend towards increased use of breastmilk substitutes and hospital practices that were detrimental to breastfeeding, the WHO and United Nations Children's Fund (UNICEF) published a joint statement: Protecting, Promoting, and Supporting Breastfeeding (WHO & UNICEF, 1989). This statement included Ten Steps to Successful Breastfeeding (Ten Steps; see Figure 1).

Figure 1.

World Health Organization/United Nations Children's Fund Ten Steps To Successful Breastfeeding (original version: 1989 and revised version: 2018)

In 1991, WHO and UNICEF launched the global Baby‐Friendly Hospital Initiative (BFHI) as a facility‐based action to provide optimal clinical care and support to mothers and their infants (WHO and UNICEF, 1992). The BFHI achieves this purpose by ensuring maternity facilities adopt and implement the Ten Steps. Current evidence, collated in a narrative systematic review, has demonstrated that adherence to the Ten Steps impacts rates of breastfeeding (early initiation immediately after birth, exclusive breastfeeding, and total duration of any breastfeeding). Further, there is a dose–response relationship between the number of BFHI steps women are exposed to and the likelihood of improved breastfeeding outcomes (Pérez‐Escamilla, Martinez, & Segura‐Pérez, 2016). To become “Baby friendly,” a facility that provides maternity services must adopt and demonstrate capacity to implement the Ten Steps (UNICEF, 2009). Thereafter, an initial self‐assessment followed by an assessment by an external team of assessors is needed to designate a facility as “Baby friendly,” if it meets the standards. These standards are implemented on the basis of a set of guidance and assessment tools used at facility level to ensure infants and mothers receive appropriate support to successfully breastfeed their infants. However, after nearly three decades, it is evident that implementation of the BFHI is far from optimal (WHO, 2017a). Currently, only an estimated 10% of children are delivered in facilities that are certified as “Baby friendly.” This is due to multiple factors including country inertia to own and invest in the implementation of the ten steps, irregular monitoring of facility services, and nonenforcement of quality standards at facility level (UNICEF & WHO, 2017). As a result, in many countries, BFHI remains unsustainable without external support.

The BFHI has undergone several reviews. It was first updated in 2006 following extensive user surveys that allowed incorporation of new evidence, including “breastfeeding in the context of HIV,” and “mother‐friendly care” (WHO & UNICEF, 2013). This allowed the BFHI to be relaunched in 2009. More recently, the WHO and UNICEF have evaluated the BFHI by assessing the current state of implementation. A wide variety of approaches have been utilized in this evaluation process to include case studies, key informant interviews, and a global policy survey (UNICEF & WHO, 2018). In addition, and crucially, the WHO developed a guideline on protecting, promoting, and supporting breastfeeding in facilities providing newborn services. This was based on 22 systematic reviews following procedures of the Cochrane Handbook for Systematic Reviews, plus qualitative syntheses using the GRADE‐CERQual approach (WHO, 2017b). From this evaluation, what is clear is that implementation of the BFHI and its accompanying steps has ensured improved attitudes and skills of care providers, dramatic reductions in use of formula, reduced separation of infants from their mothers, and made nurseries an uncommon practice. Beyond these, BFHI has also led to facility‐wide changes to protect, promote, and support breastfeeding in a baby‐friendly environment (UNICEF & WHO, 2018). It has also unearthed important implementation challenges that must be surmounted to ensure improved scale‐up of appropriate quality standards that are sustainable. Out of these challenges, lessons must be learned that will stimulate and re‐energize BFHI in all countries. A key lesson is to prioritize state funding for BFHI at national and subnational levels. There is a need to sustain standards of implementation by investing in a well‐trained facility staff to deliver services through in‐service as well as preservice training programs. These staff should be supported by higher‐level specialist coaches who will motivate them to keep their status beyond the initial passion of designation. It is also important to cultivate and sustain champions at facility level who will not only advocate for breastfeeding standards but also to pass on the passion. The evaluation has given opportunity for revising again the Ten Steps underlying the BFHI (see Figure 1). While the basic themes have been maintained, the Ten Steps have been reworded and in some cases, updated with new components to better reflect the current evidence and practice realities. The Ten Steps have now been divided into critical management procedures to support breastfeeding (Steps 1 and 2) and key clinical practices to support breastfeeding (Steps 3‐10). Important changes include incorporation of compliance with the International Code of Marketing of Breast‐Milk Substitutes (WHO, 1981) and internal monitoring into Step 1; a focus on staff knowledge and competence has been embedded in Step 2. Step 5 now has a broader scope that includes positioning, suckling, and competence of the lactating mother. The emphasis in Step 8 is now towards the relational aspects of breastfeeding with emphasis on responsiveness to infant cues. The changes in Step 9 are perhaps the most controversial with the new guidance taking a significant position shift in its recommendation to, “counsel mothers on the use and risks of feeding bottles, teats, and pacifiers,” which is a departure from the earlier position of avoiding reference to these technologies. This, in no way suggests a relaxation in the emphasis upon protection, promotion, and support of breastfeeding but rather a recognition that parents who decide not to exclusively breastfeed, need support in optimizing their alternative approaches to feeding. Step 10 shifts responsibility to facilities providing maternity and newborn services to plan and facilitate provision of ongoing community support for mothers rather than relying of mother‐to‐mother support groups.

Beyond the Ten Steps, the new guidance on BFHI proposes actions to enable states to improve coverage and standards in BFHI implementation. These include scaling up BFHI coverage in both public and private facilities, integrating the BFHI into existing initiatives in the health system and even beyond, ensuring adequate capacity of health system staff, and regular monitoring and taking corrective action to ensure standards are maintained. External monitoring is also emphasized to ensure appropriate service delivery. These programmatic changes should be implemented in a way that is consistent with the Ten Steps.

3. MONITORING AND LEARNING FROM IMPLEMENTATION

It is important to consider further research questions related to actual implementation of the revised BFHI to update existing knowledge (Pérez‐Escamilla et al., 2016; Schmied et al., 2014). Recognizing that scaling up breastfeeding takes place in a complex adaptive world (Pérez‐Escamilla & Hall Moran, 2016), we could use ecological perspectives to further explore the ways in which change in relation to the revised BHFI is managed at a macro (society level), meso (community level), and micro (individual level; McLaren & Hawe, 2005). This perspective may be adapted to health‐care systems with macro relating to the social, economic, and health policy contexts; meso relating to the maternity and newborn care environments, organization of care, staffing structures and leadership; and micro relating to individual experiences and perspectives (Dykes, Thomson, Gardner, Hall Moran, & Flacking, 2016). Research is increasingly showing the importance of person‐centred approaches for women (Schmied, Beake, Sheehan, McCourt, & Dykes, 2011) and prioritizing relationships to better facilitate mothers' capacities to respond to their babies' cues (Dykes & Flacking, 2010; Thomson, Bilson, & Dykes, 2012). Thus, we need studies that include in‐depth ethnographic exploration of implementation of the BFHI, to explore and observe implementation of the revised Ten Steps and the acceptability for parents using the maternity and newborn services. These studies need to be conducted in a range of country and cultural contexts with cross‐cultural comparative processes embedded.

4. CONCLUSION

Over 25 years since initial implementation, the BFHI is yet again at the starting line of a new phase. Will it keep the same low scale‐up pattern evident over the last few years, or will it see renewed state‐led action aimed at making all maternity facilities “Baby friendly”? The pathway will depend very much on the current context in each country or state. To be successful, it is important to situate the country context within the broader program framework with consideration for adequate advocacy and buy in from champions and decision makers who will provide the needed resources for action (Pérez‐Escamilla et al., 2018). In countries where positive change will occur in response to the revised guidance on BFHI, there will be appropriate investment in capacity at national and subnational levels. In addition, a strengthened monitoring system at facility level as well as at higher levels will be useful to determine an appropriate course of action.

CONFLICTS OF INTEREST

The authors declare that they have no conflicts of interest.

CONTRIBUTIONS

Both authors contributed equally to the manuscript.

Aryeetey R, Dykes F. Global implications of the new WHO and UNICEF implementation guidance on the revised Baby‐Friendly Hospital Initiative. Matern Child Nutr. 2018;14:e12637 10.1111/mcn.12637