by Donna Walls, RN, ICCE, IBCLC, ANLC

The Baby Friendly Hospital Initiative was developed and implemented by the World Health Organization and UNICEF in 1991.  These organizations recognized the importance of breastfeeding to the health of infants and babies as well as the influence the formula industry marketing on parents making the decision of how to feed their newborns. There was also recognition that in many countries hospitals and birth centers continued practices that undermined breastfeeding success.

Baby-Friendly USA announced a significant milestone in the efforts to implement Baby-Friendly practices in hospitals and birth centers across the country: More than 1 million babies are now born each year in Baby-Friendly designated facilities in the US.  In 2007, less than 3% of US births occurred in approximately 60 Baby-Friendly designated facilities. In 2018, these numbers have risen to more than 25% of births in more than 500 Baby-Friendly designated facilities. Baby-Friendly protocols are now standard practice in birthing centers across the country, even for many facilities that are not officially designated as Baby-Friendly institutions.  (Baby Friendly USA 2018)

The foundation of this initiative is based on the evidence-based practices shown to enable new mothers to optimally breastfeed in the first days after birth, the Ten Steps to Successful Breastfeeding. These practices include:

1. Have a breastfeeding policy which is routinely communicated to all staff
2. Train all health care staff to implement these policies
3. Inform all pregnant women about benefits and management of breastfeeding
4. Initiate breastfeeding within ½-1 hour after birth
5. Show Mothers how to maintain lactation if they are separated from their babies
6. Give newborns no supplements unless medically indicated
7. Practice rooming-in, allow Mothers and babies to remain together
8. Encourage breastfeeding on demand
9. Give no artificial teats or pacifiers
10. Foster the establishment of BF support groups and refer Mothers to them on discharge from the hospital

As the number of hospitals being designated as Baby Friendly rises, misinformation persists concerning the designation. One rumor is that formula feeding families are “not welcomed” or “made to feel guilty” if not breastfeeding. In reality just the opposite is true. Although breastfeeding benefits and management are discussed, Baby Friendly hospitals require that formula preparation instructions be given on an individual basis to those families who have chosen to formula feed. Practices such as skin to skin care, rooming-in and responsive cue feeding benefit all babies, not just breastfeeding newborns. So, what can childbirth educators, doulas and all maternity care providers do to inform expectant and pregnant families about the Baby Friendly Hospital Initiative?

1. Include benefits of breastfeeding to both mother and baby in both childbirth education and infant feeding classes
2. Discuss basic breastfeeding management in prenatal classes and/or prenatal care visits
   1. How to assure immediate skin to skin care as well as continued throughout the early postpartum days
   2. The importance of avoiding scheduled feedings and teaching infant feeding cues/ responsive feeding
   3. Help parents understand the importance of the normal feeding pattern of minimum of 8, preferably 10-12 feeding for each 24 hours
   4. Teach correct latch techniques
   5. Discuss the importance of nonseparation of mother and baby
3. Provide written information on the Ten Steps to Successful Breastfeeding
4. Discuss with patients how to advocate for themselves and their newborns while in the hospital or birth center
5. Provide lactation resources in the hospital and in the community after discharge
6. Give information on how to locate local Baby Friendly hospitals

In 2017 WHO and UNICEF began an updating, revising process to the Ten Steps to Successful Breastfeeding incorporating recent research and recommendations from many global maternal-child health advocates. The recommendations include:

1. In these updates the WHO and UNICEF will retain the order, number and subject matter of each of the original Ten Steps
2. Keep the Baby Friendly Hospital Initiative about healthy term infants. There will be an adoption of a separate set of standards pertaining to breastfeeding support for preterm and sick infants, such as the NEO BFHI Baby-Friendly Hospital Initiative for Neonatal Wards, initially developed by the Nordic-Quebec Working Group.
3. Step 1 will include language supporting the International Code of Marketing of Breastmilk Substitutes and add data collection and monitoring systems.
4. Changes to Step 9 will clarify the facility’s responsibility for minimizing the use of bottles, teats and pacifiers;  including language about risks, and the advisability of using only when medically necessary.
5. Maintain standardized model 20 hour training course
6. Continue designation based on external assessment, inclusive of mother interviews, and conducted by knowledgeable individuals, as part of the process.
7. Maintain the standard that the facility must meet the current 80% passage of the step.
8. Continue safe and respectful birth practices as a component of the BFHI.
9. Step 4 has been updated to: facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth
10. Replacing feeding “on demand” is the new language: Mothers should be encouraged to practice responsive feeding as part of nurturing care.

Other key components of the revisions:

1. Stresses the importance of exclusive breastfeeding for 6 months to provide the nurturing, nutrients and energy needed for physical and neurological growth and development
2. Stresses the need for all Ten Steps to be implemented as a package in order to attain an optimal impact on breastfeeding
3. Provides updated guidance for the safe implementation of practices and monitoring of patients. Reminds health care providers of the importance of individualized attention and care.
4. Describes the importance of mother-friendly birth practices and the impact of birth practices on breastfeeding. Stresses the importance of healthcare professionals being knowledgeable about those practices and their responsibility for educating mothers.  Refers them to other WHO guidelines for more details on the specific practices.
5. Reinforces the role of facilities providing maternity and newborn services of identifying appropriate community resources for continued and consistent breastfeeding support that is culturally and socially sensitive to the needs of families. Reminds facilities they have a responsibility to engage with the surrounding community to enhance such resources.

Baby Friendly USA is working to ensure that a provision is included in a resolution for the upcoming World Health Assembly to request the Director General of WHO to work in collaboration with UNICEF to develop tools for training, monitoring, and advocacy on the Baby-Friendly Hospital Initiative to assist Member States with implementation. For more information and updating, fin the most current information on BabyFriendlyUSA.org.

References

World Health Organization, United Nations Children’s Fund, Wellstart International. The Baby-friendly Hospital Initiative: monitoring and reassessment: tools to sustain progress. Geneva: World Health Organization; 1991 (WHO/NHD/99.2; https://apps.who.int/iris/handle/10665/65380, accessed 7 March 2018). Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475–90. doi:10.1016/S0140-6736(15)01024-7. Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/bitstream/10665/259386/1/9789241550086-eng.pdf?ua=1, accessed 7 March 2018). Standards for improving quality of maternal and newborn care in health facilities. Geneva: World Health Organization; 2016 (https://apps.who.int/iris/bitstream/10665/249155/1/9789241511216-eng.pdf?ua=1, accessed 7 March 2018). WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf, accessed 7 March 2018). United Nations Children’s Fund. UNICEF data: monitoring the situation of children and women. Access the data: infant and young child feeding (https://data.unicef.org/topic/nutrition/infant-and-young-childfeeding/, accessed 7 March 2018). Smith ER, Hurt L, Chowdhury R, Sinha B, Fawzi W, Edmond KM et al. Delayed breastfeeding initiation and infant survival: a systematic review and meta-analysis. PLoS One. 2017;12(7):e0180722. doi:10.1371/journal.pone.0180722.