Baby-Friendly Hospital Initiative: Implementation Guidance
Baby-Friendly Hospital Initiative: Implementation Guidance
Baby-Friendly Hospital Initiative: Implementation Guidance
2018
IMPLEMENTATION GUIDANCE
ISBN 978-92-4-151380-7
© World Health Organization and the United Nations Children’s Fund (UNICEF) 2018
This joint report reflects the activities of the World Health Organization (WHO) and the United Nations Children’s
Fund (UNICEF).
Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike
3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided
the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO
or UNICEF endorses any specific organization, products or services. The unauthorized use of the WHO or UNICEF
names or logos is not permitted. If you adapt the work, then you must license your work under the same or equivalent
Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along
with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is
not responsible for the content or accuracy of this translation. The original English edition shall be the binding and
authentic edition”.
Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules
of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules).
Suggested citation. Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn
services: implementing the revised Baby-friendly Hospital Initiative 2018. Geneva: World Health Organization and
the United Nations Children’s Fund (UNICEF), 2018. Licence: CC BY-NC-SA 3.0 IGO.
Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests
for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing.
Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables,
figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain
permission from the copyright holder. The risk of claims resulting from infringement of any third-party- owned
component in the work rests solely with the user.
General disclaimers. The designations employed and the presentation of the material in this publication do not imply
the expression of any opinion whatsoever on the part of WHO or UNICEF concerning the legal status of any country,
territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines
on maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or
recommended by either WHO or UNICEF in preference to others of a similar nature that are not mentioned. Errors
and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
All reasonable precautions have been taken by WHO and UNICEF to verify the information contained in this publication.
However, the published material is being distributed without warranty of any kind, either expressed or implied.
The responsibility for the interpretation and use of the material lies with the reader. In no event shall either WHO or
UNICEF be liable for damages arising from its use.
Printed in Switzerland.
Content
Forewordv
Acknowledgementsvi
Executive summary vii
Scope and purpose viii
1. Introduction 1
1.1. Breastfeeding matters 1
1.2. The Baby-friendly Hospital Initiative: an overview 2
1.3. Strengths and impact of the Baby-friendly Hospital Initiative 3
1.4. Challenges in implementing the Baby-friendly Hospital Initiative 5
1.5. Revision of the Ten Steps to Successful Breastfeeding and the implementation guidance 7
Revision of the Ten Steps to Successful Breastfeeding 7
Revision of the country-level implementation guidance 9
2.3. Coordination 22
2.4. Quality-improvement process 22
iii
3. Country-level implementation and sustainability 25
3.1. National leadership and coordination 26
3.2. Policies and professional standards of care 26
3.3. Health professional competency building 27
3.4. External assessment 28
3.5. Incentives and sanctions 29
3.6. Technical assistance to facilities 31
3.7. National monitoring 32
3.8. Communications and advocacy 33
3.9. Financing 34
4. Coordination of the Baby-friendly Hospital Initiative with other breastfeeding
support initiatives outside facilities providing maternity and newborn services 35
5. Transition of BFHI implementation 37
5.1. Countries with a well-functioning national “Baby-friendly” hospital designation programme 37
5.2. Countries without an active or successful BFHI programme 37
Annex 1. Ten Steps to Successful Breastfeeding – revised 2018 version: comparison
to the original Ten Steps and the new 2017 WHO guideline 39
Annex 2. Ten Steps to Successful Breastfeeding in lay terms 43
Annex 3. External review group members 45
References47
iv
Foreword
It is estimated that over 820,000 deaths among children under age 5 could be prevented worldwide every year if
all children were adequately breastfed. Breastfeeding promotes brain development, reduces the risk of obesity in
children, and protects women against breast and ovarian cancer and diabetes. Facilities that provide maternity and
newborn services have a unique role in providing new mothers and babies with the timely and appropriate support
and encouragement they need to breastfeed successfully, saving governments money while saving lives.
Almost 30 years ago, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) came
together to advocate for the protection, promotion and support of breastfeeding in facilities providing maternity
and newborn services. The 1989 Joint WHO-UNICEF statement included a list of measures that came to be known as
the Ten Steps.
Translated into more than 25 languages, the joint WHO–UNICEF Statement became the centrepiece for the Baby
Friendly Hospital Initiative. Since 1991, maternity wards and hospitals applying the Ten Steps have been designated
“Baby-friendly” to draw public attention to their support for sound infant-feeding practices.
To date, nearly all the countries of the world have implemented the BFHI, helping save infants’ lives and support
mothers’ health. But many countries still struggle to maintain the programme and take it to full scale.
Starting in 2015, WHO and UNICEF coordinated a process to review the scientific evidence behind the Ten Steps and to
strengthen implementation of the Initiative, which included systematic literature reviews, a thorough examination
of the success factors and challenges of the BFHI, and a BFHI Congress in 2016, at which 130 countries came together
to discuss the new directions needed to reach universal coverage and sustainability of the BFHI.
The updated guidance published here reflects this collaborative effort to build a more robust programme that will
sustain improved quality of care over time. It describes practical steps that countries can and must take to protect,
promote and support breastfeeding in facilities providing maternity and newborn services. The guidance emphasizes
the importance of applying the Ten Steps in all facilities, for all babies, whether premature or full term, born in private
or public facilities, or in rich or poor countries.
WHO and UNICEF are committed to supporting breastfeeding as an effective and cost-effective way to promote the
survival, nutrition, growth and development of infants and young children, to protect the health and well-being of
their mothers, and to help all children to reach their full potential. We believe the Ten Steps offer health facilities and
health workers around the world the guidance they need to help more mothers to successfully breastfeed. Together,
we can give every newborn the healthiest start in life.
v
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
Acknowledgements
The development of this guidance document was coordinated by the World Health Organization (WHO) Department of
Nutrition for Health and Development and the United Nations Children’s Fund (UNICEF) Nutrition Section, Programme
Division. Dr Laurence Grummer-Strawn and Ms Maaike Arts oversaw the preparation of this document.
We gratefully acknowledge the technical input, planning assistance and strategic thinking of the external review
group throughout the process (in alphabetical order): Ms Genevieve Becker, Dr Ala Curteanu, Dr Teresita Gonzalez de
Cosío, Dr Rukhsana Haider, Dr Miriam H Labbok, Dr Duong Huy Luong, Dr Chessa Lutter, Dr Cria G Perrine, Ms Randa
Saadeh, Dr Isabella Sagoe-Moses and Ms Julie Stufkens.
Over 300 participants in the 2016 Baby-friendly Hospital Initiative (BFHI) Congress, representing 130 countries and
numerous non-governmental organizations, donors and professional associations, provided invaluable insights to
the successes of and challenges for the BFHI, and outlined many of the priorities for future activity. We would like to
thank the members of the BFHI Congress planning committee for their insights in shaping this useful meeting (in
alphabetical order): Ms Maite Hernández Aguilar, Ms Funke Bolujoko, Dr Anthony Calibo, Ms Elsa Giuliani, Ms Trish
MacEnroe and Ms Agnes Sitati.
We would like to express our gratitude to the following colleagues for their assistance and technical input throughout
the process (in alphabetical order): WHO – Ms Shannon Barkley, Dr Francesco Branca, Ms Olive Cocoman, Dr Bernadette
Daelmans, Ms Diana Estevez, Ms Ann-Lise Guisset, Dr Frances McConville, Ms Natalie Murphy, Ms Thahira Shireen
Mustafa, Dr Lincetto Ornella, Dr Juan Pablo Peña-Rosas, Dr Pura Rayco-Solon, Mr Marcus Stahlhofer, Dr Helen
Louise Taylor, Dr Wilson Were and the WHO regional nutrition advisers; UNICEF – Dr Victor Aguayo, Dr France
Bégin, Mr David Clark, Dr Aashima Garg, Dr David Hipgrave, Ms Diane Holland, Ms Irum Taqi, Ms Joanna Wiseman
Souza Dr Marilena Viviani, Dr Nabila Zaka, and the UNICEF regional nutrition advisers and regional health advisers.
We gratefully acknowledge the input from the 300 external reviewers who commented on the draft document in
October 2017, and the staff, volunteers and members of the BFHI Network, La Leche League (LLL), the International
Baby Food Action Network (IBFAN), the International Lactation Consultants’ Association (ILCA) and the World
Alliance for Breastfeeding Action (WABA), who provided additional input. We are grateful for the input of Dr Pierre
Barker on quality-improvement processes.
Finally, we would like to thank the many BFHI coordinators and hospital administrators who have implemented the
BFHI at national, regional and facility levels over the past 27 years. Their hard work and passion for the health of
mothers and babies has strengthened the initiative throughout the world.
vi
The Revised Baby-friendly Hospital Initiative 2018
Executive summary
The first few hours and days of a newborn’s life are a critical window for establishing lactation and for providing
mothers with the support they need to breastfeed successfully. Since 1991, the Baby-friendly Hospital Initiative (BFHI)
has helped to motivate facilities providing maternity and newborn services worldwide to better support breastfeeding.1
Based on the Ten Steps to Successful Breastfeeding (the Ten Steps),2 the BFHI focuses on providing optimal clinical
care for new mothers and their infants. There is substantial evidence that implementing the Ten Steps significantly
improves breastfeeding rates.
The BFHI has been implemented in almost all countries in the world, with varying degrees of success. After more
than a quarter of a century, coverage at a global level remains low. As of 2017, only 10% of infants in the world
were born in a facility currently designated as “Baby-friendly”.3 Countries have found it difficult to sustain a BFHI
programme, with implementation often relying on specific individual and external resources. The programme has
characteristically been implemented as a vertical intervention focused on designating facilities that volunteer to take
part in the programme and can document their full adherence to the Ten Steps. Facilities may make changes in their
policies and procedures to obtain the designation, but these changes are not always sustainable, especially when there
are no regular monitoring systems in place.
In 2015, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) began a process to
re-evaluate and reinvigorate the BFHI programme. Case-studies, key informant interviews, a global policy survey and
literature reviews were conducted to better understand the status and impact of the initiative. Systematic literature
reviews were commissioned to carefully examine the evidence for each of the Ten Steps. WHO convened a guideline
development group to write the WHO guideline Protecting, promoting and supporting breastfeeding in facilities providing
maternity and newborn services4 and an external review group to update the guidance on country- level implementation
of the BFHI. The main concepts and outline of the updated implementation guidance were discussed extensively at the
BFHI Congress in October 2016, involving approximately 300 participants from over 130 countries. The draft updated
guidance document was disseminated through an online consultation in October 2017 and comments from over 300
respondents were considered in the final revisions of the document.
This updated implementation guidance is intended for all those who set policy for, or offer care to, pregnant women,
families and infants: governments; national managers of maternal and child health programmes in general, and of
breastfeeding- and BFHI-related programmes in particular; and health-facility managers at different levels (facility
directors, medical directors, chiefs of maternity and neonatal wards). The document presents the first revision of the
Ten Steps since 1989. The topic of each step is unchanged, but the wording of each one has been updated in line with the
evidence-based guidelines and global public health policy. The steps are subdivided into (i) the institutional procedures
necessary to ensure that care is delivered consistently and ethically (critical management procedures); and (ii) standards
for individual care of mothers and infants (key clinical practices). Full application of the International Code of Marketing
of Breast-milk Substitutes5 and relevant World Health Assembly Resolutions (the Code),6 as well as ongoing internal
monitoring of adherence to the clinical practices, have been incorporated into step 1 on infant feeding policies.
The implementation guidance also recommends revisions to the national implementation of the BFHI, with an emphasis
on scaling up to universal coverage and ensuring sustainability over time. The guidance focuses on integrating the
programme more fully in the health-care system, to ensure that all facilities in a country implement the Ten Steps.
Countries are called upon to fulfil nine key responsibilities through a national BFHI programme, including establishing
or strengthening a national coordination body; integrating the Ten Steps into national policies and standards; ensuring
the capacity of all health-care professionals; using external assessment to regularly evaluate adherence to the Ten
Steps; incentivizing change; providing necessary technical assistance; monitoring implementation; continuously
communicating and advocating; and identifying and allocating sufficient resources.
1 World Health Organization, United Nations Children’s Fund. The Baby-friendly Hospital Initiative: monitoring and reassessment: tools to sustain
progress. Geneva: World Health Organization; 1991 (WHO/NHD/99.2; http://apps.who.int/iris/handle/10665/65380).
2 Protecting, promoting and supporting breast-feeding: the special role of maternity services. A joint WHO/UNICEF statement. Geneva: World Health
Organization; 1989 (http://apps.who.int/iris/bitstream/10665/39679/1/9241561300.pdf).
3 National implementation of the Baby-friendly Hospital Initiative. Geneva: World Health Organization; 2017 (http://apps.who.int/iris/bitstre
am/10665/255197/1/9789241512381-eng.pdf?ua=1).
4 Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. Geneva: World Health Organization;
2017 (http://apps.who.int/iris/bitstream/10665/259386/1/9789241550086-eng.pdf?ua=1).
5 International Code of Marketing of Breast-milk Substitutes. Geneva: World Health Organization; 1981 (http://www.who.int/nutrition/publications/
code_english.pdf); The International Code of Marketing of Breast-Milk Substitutes – 2017 update: frequently asked questions. Geneva: World Health
Organization; 2017 (http://apps.who.int/iris/bitstream/10665/254911/1/WHO-NMH-NHD-17.1-eng.pdf?ua=1).
vii
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
The BFHI focuses on protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn
services. It is understood that many other interventions are needed to ensure adequate support for breastfeeding,
including in antenatal care, postpartum care, communities and workplaces, as well as adequate maternity protection
and Code legislation. It is critical that the BFHI programme is integrated with all other aspects of breastfeeding
protection, promotion and support.
By reinvigorating the BFHI and ensuring that all facilities adhere to evidence-based recommendations on maternity
and newborn care, breastfeeding rates can be substantially increased and the health of mothers and children
dramatically improved.
The core purpose of the BFHI is to ensure that mothers and newborns receive timely and appropriate care before
and during their stay in a facility providing maternity and newborn services, to enable the establishment of optimal
feeding of newborns, which promotes their health and development. Given the proven importance of breastfeeding (2),
the BFHI protects, promotes and supports breastfeeding, while enabling timely and appropriate care and feeding of
newborns who are not breastfed.
This document complements the World Health Organization (WHO) Guideline: protecting, promoting and supporting
breastfeeding in facilities providing maternity and newborn services (3). It also complements existing Standards for improving
quality of maternal and newborn care in health facilities (4), Guidelines on the optimal feeding of low birth- weight infants
in low- and middle-income countries (5), WHO recommendations: intrapartum care for a positive childbirth experience (6)
and other guidance documents on maternal and newborn care. It is crucial that the BFHI is implemented within a
broader context of support for breastfeeding in families, communities and the workplace. This document does not
address these areas specifically.
The intended audience of this document includes all those who set policy for, or offer care to, pregnant women,
families and infants: governments; national managers of maternal and child health programmes in general, and of
breastfeeding- and BFHI-related programmes in particular; and health-facility managers at different levels (facility
directors, medical directors, chiefs of maternity and neonatal wards).
viii
The Revised Baby-friendly Hospital Initiative 2018
1. Introduction
1.1. Breastfeeding matters Recent analyses have documented that increasing
rates of breastfeeding could add US$ 300 billion to the
Breastfeeding is the biological norm for all mammals, global economy annually, by helping to foster smarter,
including humans. Breastfeeding is critical for achieving more productive workers and leaders (13). In Brazil, adults
global goals on nutrition, health and survival, economic who had been breastfed for at least 12 months earned
growth and environmental sustainability. WHO and the incomes that were 33% higher than for those who had
United Nations Children’s Fund (UNICEF) recommend been breastfed for shorter durations (14). Inadequate
that breastfeeding be initiated within the first hour after breastfeeding has a significant impact on the costs of
birth, continued exclusively for the first 6 months of life health care for children and women (15, 16). Mothers
and continued, with safe and adequate complementary who feed their infants on formula are absent from work
foods, up to 2 years or beyond (7). Globally, a minority more often than breastfeeding mothers, owing to a higher
of infants and children meet these recommendations: frequency and severity of infant illness (17).
only 44% of infants initiate breastfeeding within the first
hour after birth and 40% of all infants under 6 months
of age are exclusively breastfed. At 2 years of age, 45% Recent analyses have
of children are still breastfeeding (8).
documented that
Immediate and uninterrupted skin-to-skin contact and
initiation of breastfeeding within the first hour after birth
are important for the establishment of breastfeeding,
increasing rates of
and for neonatal and child survival and development.
The risk of dying in the first 28 days of life is 33% higher
breastfeeding could
for newborns who initiated breastfeeding 2–23 hours after
birth, and more than twice as high for those who initiated
add US$ 300 billion
to the global
1 day or longer after birth, compared to newborns who
were put to the breast within the first hour after birth
(9). The protective benefit of early initiation extends
until the age of 6 months (10). economy annually
Exclusive breastfeeding for 6 months provides the
Breastfeeding is a non-polluting, non-resource- intensive,
nurturing, nutrients and energy needed for physical
sustainable and natural source of nutrition and sustenance.
and neurological growth and development. Beyond
Breast-milk substitutes add to greenhouse gas emissions
6 months, breastfeeding continues to provide energy
at every step of production, transport, preparation and
and high-quality nutrients that, jointly with safe and
use. They also generate waste, which requires disposal.
adequate complementary feeding, help prevent hunger,
Greenhouse gases include methane, nitrous oxide and
undernutrition and obesity (11). Breastfeeding ensures
carbon dioxide; a recent report estimated the carbon
food security for infants (8).
dioxide emissions resulting from manufacture of infant
formula in Asia at 2.9 million tons (18).
Inadequate breastfeeding practices significantly impair
the health, development and survival of infants, children
In humanitarian settings, the life-saving potential of
and mothers. Improving these practices could save
breastfeeding is even more crucial (7). International
over 820 000 lives a year (2). Nearly half of diarrhoea
guidance recommends that all activities to protect,
episodes and one third of respiratory infections are
promote and support breastfeeding need to be increased
due to inadequate breastfeeding practices. Longer
in humanitarian situations, to maintain or improve
breastfeeding is associated with a 13% reduction in the
breastfeeding practices (19).
likelihood of overweight and/or prevalence of obesity and
a 35% reduction in the incidence of type 2 diabetes (2).
An estimated 20 000 maternal deaths from breast cancer
could be prevented each year by improving rates of
breastfeeding (2).
1
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
Breastfeeding is a vital component of realizing every In 1989, WHO and UNICEF published the Ten Steps
child’s right to the highest attainable standard of health, to Successful Breastfeeding (the Ten Steps), within a
while respecting every mother’s right to make an informed package of policies and procedures that facilities providing
decision about how to feed her baby, based on complete, maternity and newborn services should implement to
evidence-based information, free from commercial support breastfeeding (23). The Innocenti Declaration
interests, and the necessary support to enable her to on the protection, promotion and support of breastfeeding,
carry out her decision (20). adopted in Florence in 1990 (24), called for all governments
to ensure that every facility providing maternity and
Improving breastfeeding can be a key driver for achievement newborn services fully practises all 10 of the Ten Steps.
of the Sustainable Development Goals (21). Breastfeeding In 1991, WHO and UNICEF launched the Baby-friendly
can be linked to several of the goals, including goals 1 (end Hospital Initiative (BFHI) (1), to help motivate facilities
poverty in all its forms everywhere); 2 (end hunger, achieve providing maternity and newborn services worldwide to
food security and promote sustainable agriculture); implement the Ten Steps. Facilities that documented their
3 (ensure healthy lives and promote well-being for all full adherence to the Ten Steps, as well as their compliance
at all ages) 4 (ensure inclusive and quality education with the International Code of Marketing of Breast-milk
for all and promote lifelong learning); 5 (achieve gender Substitutes (25, 26) and relevant World Health Assembly
equality and empower all women and girls); 8 (promote (WHA) resolution (the Code) (27), could be designated as
sustained, inclusive and sustainable economic growth, “Baby-friendly”. WHO published accompanying evidence
employment and decent work for all); 10 (reduce inequality for each of the Ten Steps in 1998 (28).
within and among countries); and 12 (ensure sustainable
consumption and production patterns).
The first few hours and
1.2. The Baby-friendly Hospital
Initiative: an overview days of a newborn’s life
The first few hours and days of a newborn’s life are a critical are a critical window for
window for establishing lactation and providing mothers
with the support they need to breastfeed successfully. establishing lactation
This support is not always provided, as illustrated by a
review of UNICEF data showing that 78% of deliveries
were attended by a skilled health provider, but only 45%
and providing mothers
of newborns were breastfed within the first hour after
birth (8, 22). Although breastfeeding is the biological
with the support they
norm, health professionals may perform inappropriate
procedures that interfere with the initiation of need to breastfeed
successfully
breastfeeding, such as separation of the mother and infant;
delayed initiation of breastfeeding; provision of pre-
lacteal feeds; and unnecessary supplementation. These
procedures significantly increase the risk of breastfeeding
Several global health-policy documents have emphasized
challenges that lead to early cessation. Families need to
the importance of the Ten Steps. WHA resolutions in
receive evidence-based information and counselling about
1994 and 1996 called for specific action related to the
breastfeeding and must be protected from commercial
BFHI (29, 30). The 2002 Global strategy for infant and
interests that negatively impact on breastfeeding.
young child feeding called upon all facilities providing
maternity and newborn services worldwide to implement
the Ten Steps (7). At the 15th anniversary of the Innocenti
Declaration (24) in 2005, the Innocenti partners issued
a call to action, which included a call to revitalize the
BFHI, maintaining the global criteria as the minimum
requirement for all facilities and expanding the initiative’s
application to include maternity, neonatal and child health
services and community-based support for lactating
women and caregivers of young children (31).
2
The Revised Baby-friendly Hospital Initiative 2018
The BFHI package was updated in 2006 after extensive Almost all countries in the world have implemented
user surveys, and relaunched in 2009 (32). The updated the BFHI at some point in time. Coverage within most
package reflected the new evidence for some of the steps countries has remained low, however. In 2011, it was
(steps 4 and 8 for example) and their interpretation, estimated that 28% of all facilities providing maternity
and specifically addressed the situation of women living and newborn services had been designated as “Baby-
with HIV. It included guidelines for “mother-friendly friendly at some point in time” (39). However, as of
care” and described breastfeeding-friendly practices in 2017, WHO estimated that only about 10% of babies in
other facilities and communities. Standards for providing the world were born in a facility currently designated
support for “non-breastfeeding mothers” were included, as “Baby-friendly” (40). The impact of the initiative is
as the initiative encompasses ensuring that all mothers, probably greater than this number implies, since facilities
regardless of feeding method, get the feeding support might implement several of the Ten Steps without having
they need. The package included updated training and reached designation as “Baby- friendly”, but there are
assessment tools. currently no global systems to assess this.
breastfeeding the hospitals that did not receive the intervention (41).
3
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
One study based in the United States of America (USA) In anticipation of the 25th anniversary of the BFHI,
found that adherence to six of the specific maternity- care WHO and UNICEF undertook a broad-based assessment of
practices could reduce the odds of early termination of the current status of the initiative. A global survey among
breastfeeding 13-fold (see Fig. 1) (43). all WHO Member States on the implementation at country
level was conducted in June to August 2016, with responses
received from 117 countries (40). In-depth case-studies
35
on how the initiative has operated in 13 countries were
30.0
30 solicited from ministries of health, non-governmental
stopped breastfeeding
26.9
BFHI coordinators and UNICEF staff; key informant
% of mothers who
25
before 6 weeks
21.5
interviews with the BFHI coordinators (including
20
15.5 government officials and staff of non-governmental
15 13.7 organizations (NGOs) in 22 countries) provided additional
10 insights regarding challenges and lessons learnt over the
6.2
5 first 25 years of the initiative (40, 46).
3.2
0
0 1 2 3 4 5 6 The information gathered in the case-studies and
Number of “Baby-friendly” practices reported key informant interviews (40, 46) indicates that the
Ann M. DiGiroiamo et al. pediatrics 2006; 122:S43-S49
implementation of the BFHI has led to improvements in
health professionals’ capacity, as well as strengthened
protection, promotion and support of breastfeeding,
Fig. 1. Among women who initiated breastfeeding and
in large numbers of facilities providing maternity and
intended to breastfeed for >2 months, the percentage
newborn services, thereby possibly contributing to
who stopped breastfeeding before 6 weeks, according
increased rates of early initiation of breastfeeding across
to the number of Baby-friendly hospital practices they
the globe. The systematic approach to improving facility
experienced (43)
policies and practices, and the visibility and rewarding
nature of the designation “Baby-friendly”, are appreciated
Experiences in BFHI implementation from that time
by many actors.
showed that national leadership (including strong
national involvement and support) was key to successful
implementation of the BFHI. National- or facility-level For facilities that were designated, the process of becoming
adaptation, ongoing facility-level monitoring, and making Baby-friendly was often transformative, changing the
the BFHI part of the continuum of care were also found whole environment around infant feeding. In many
to be important for BFHI implementation (44). countries, becoming designated has been a key motivating
factor for facilities to transform their practices. As a
consequence of this, care in these facilities became more
A recent article about the USA, which reviewed two
patient centred; staff attitudes about infant feeding
national policy documents and 16 original studies,
improved; and skill levels dramatically increased. Use of
confirmed the BFHI’s success in facilitating successful
infant formula typically dropped dramatically, and the
breastfeeding initiation and exclusivity (45). The duration
use of nurseries for newborn babies was greatly reduced.
of breastfeeding also appears to increase when mothers
The quality of care for breastfeeding clearly improved
have increased exposure to Baby- friendly practices.
in facilities that were designated as “Baby-friendly”.
However, current mechanisms for tracking breastfeeding
are suboptimal and therefore limited reliable data are
available on the duration of breastfeeding. Of the 10 steps The case-studies and interviews also captured several
of the BFHI, step 3 (antenatal education) and step 10 challenges, which are described in the next section.
(postnatal breastfeeding support) were mentioned as
the most challenging steps to implement (45); however,
these two steps have the potential to significantly impact
breastfeeding practices.
4
The Revised Baby-friendly Hospital Initiative 2018
5
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
In 2016, the Pan-American Health Organization published need for continued improvement in maternity and
a report on the BFHI in the Americas, in which they newborn care. As long as adherence to the Ten Steps
examined the years in which BFHI designations or re- is limited to only selected facilities, inequities in the
designations occurred (47). The report showed that quality of health care for newborns will persist. Achieving
for most countries in the region, BFHI designations or adherence by all facilities will require redoubled efforts
re-designations occurred almost exclusively in a single and new approaches.
5-year window of time. Some countries designated many
facilities in the 1990s but then stopped; others started
later but then stopped; and a few countries have only
recently been designating facilities. However, no country
It is difficult for
conducted more than a handful of designations outside
of a peak 10-year period (see Fig. 2 for two examples).
countries to sustain an
These results suggest that it is difficult for countries
to sustain an ongoing designation and re-designation ongoing designation
programme for more than a few years.
and re-designation
programme for more
Whereas the Ten Steps were focused on the in-facility
care of healthy, full-term infants, many countries have
expanded the concept of “Baby- friendly” into other areas
of breastfeeding support outside of facilities providing than a few years
maternity and newborn services, as suggested in the
2009 revision of the BFHI guidance (32). While these
programmes have successfully improved the quality of The case-studies and key informant interviews (40, 46)
maternal and infant care in many countries, international showed that countries have adapted the BFHI guidance
standards have not been developed to give a specific set to their own situation and possibilities. This has resulted
of criteria and evaluation tools for programmes, leading in several excellent examples of management and
to diversity in application worldwide. Guidelines are operational processes that can facilitate the sustainable
needed to improve breastfeeding support groups outside implementation and scale- up of practices that support
of facilities providing maternity and newborn services, breastfeeding. These examples, as well as a broad set of
as they each have unique aspects that cannot be addressed general lessons learnt and recommendations for achieving
within the BFHI. the protection, promotion and support of breastfeeding
in facilities providing maternity and newborn services at
scale, obtained from the case-studies and key informant
The large numbers of countries implementing the BFHI
interviews, and combined with an intensive consultative
on the one hand, and the low percentage of designated
process with the external review group (see section 1.5),
facilities on the other hand, demonstrate the broad
form the basis for this revised implementation guidance.
reach the initiative has achieved, but also indicate the
PARAGUAY MEXICO
38
17 40
18
Number of hospitals
16 35
Number of hospitals
14 30
12 25
10
20
8
15
6 10
10
4 6
1 1 5 1
2
0 0 0
0 0
1991- 1996- 2001- 2006- 2011- 1991- 1996- 2001- 2006- 2011-
1995 2000 2005 2010 2014 1995 2000 2005 2010 2014
Years Years
Fig. 2. Number of hospitals designated or re-designated by 5-year period in Paraguay and Mexico (47). Reproduced
by permission of the publisher from: Pan American Health Organization, World Health Organization Regional
Office for the Americas. The Baby Friendly Hospital Initiative in Latin America and the Caribbean: current status,
challenges, and opportunities. Washington (DC): Pan American Health Organization; 2016 (http://iris.paho.org/
xmlui/bitstream/handle/123456789/18830/9789275118771_eng.pdf?sequence=1&isAllowed=y)
6
The Revised Baby-friendly Hospital Initiative 2018
1.5. Revision of the Ten Steps to While the 2009 BFHI guidance suggested including
Successful Breastfeeding and the “mother-friendly” actions focusing on ensuring mothers’
implementation guidance physical and psychological health (32), this updated
BFHI guidance does not include guidance on these
aspects. This guidance explicitly recommends countries
In 2015, WHO and UNICEF began the process of reviewing
to integrate the Ten Steps into other programmes and
and revising both the Ten Steps to Successful Breastfeeding
initiatives for maternal and newborn health. In-depth,
and the implementation guidance for countries on how to
relevant, evidence-based guidance on the quality of care
protect, promote, and support breastfeeding in facilities
of maternal health is already available elsewhere (4), but it
providing maternity and newborn services. Using the
is important for all health professionals, whether or not
standard WHO guideline development process (48),
they are responsible for delivery or newborn care, to be
WHO established a guideline development group. Detailed
fully aware of mother-friendly practices and how they can
description of the process for developing the 2017 WHO
affect the mother, baby and breastfeeding, so that they
Guideline: protecting, promoting and supporting breastfeeding
can ensure these practices are implemented and achieve
in facilities providing maternity and newborn services (3),
the intended quality-of-care benefits. For this reason,
including the systematic literature reviews on each step,
a summary of this guidance is provided in section 2.
is published elsewhere (3). In addition, WHO convened
an external review group to provide additional expert
guidance to the guideline development group and Similarly, this document does not cover criteria for
to develop the revised implementation guidance for Baby-friendly communities, Baby-friendly paediatric
countries, presented in this document. units or Baby-friendly physicians’ offices. Support for
breastfeeding is critical in all of these settings, but is
beyond the scope of this document.
The external review group met three times in face- to-face
meetings (December 2015, April 2016 and October 2016)
and held numerous conference calls and reviewed draft Revision of the Ten Steps to
documents via email. The case-studies and interviews Successful Breastfeeding
with national BFHI leaders described above provided The 2017 WHO Guideline: protecting, promoting and
important insights to the external review group in shaping supporting breastfeeding in facilities providing maternity
the implementation guidance. An early draft of this and newborn services (3) examined the evidence for
guidance was presented at the BFHI Congress in October each of the original Ten Steps that were originally
2016 (49). Approximately 300 participants from over published in 1989 (23). Based on the new guidelines,
130 countries, and 20 development partners (NGOs, this implementation guidance rewords the Ten Steps
international professional associations and donors), while maintaining the basic theme of each step. The core
discussed the guidance in small workgroups over the intent of the steps remains the same as the 1989 version
course of 3 days, and gave extensive input to the revisions. of the Ten Steps, namely protecting, promoting and
The updated guidance was disseminated through an online supporting breastfeeding in facilities providing maternity
consultation in October 2017 and comments from over and newborn services. The guidance separates the first
300 respondents were considered in the final revisions two steps, which address the management procedures
of the document. necessary to ensure that care is delivered consistently
and ethically, and the other eight steps, which spell
This updated guidance covers only those activities that out standards for clinical care of mothers and infants.
are specifically pertinent to the protection, promotion and The updated Ten Steps are presented in Box 1.
support of breastfeeding in facilities providing maternity
and newborn services. The care of small, sick and/or Step 1 on facility breastfeeding policy has been modified
preterm newborns cannot be separated from that of full- to include three components. Application of the
term infants, as they both occur in the same facilities, Code (25–27) has always been a major component of
often attended by the same staff. As such, the care for the BFHI but was not included as part of the original Ten
these newborns in neonatal intensive care units or in Steps. This revision explicitly incorporates full compliance
regular maternity or newborn wards is included in the with the Code as a step. In addition, the need for ongoing
scope of this document. However, since this document internal monitoring of adherence to the clinical practices
focuses on global standards and is not a clinical guide, has been incorporated into step 1. Internal monitoring
it does not provide in-depth guidance on how to care for should help to ensure that adoption of the Ten Steps is
small, sick and/or preterm newborns but merely outlines sustained over time.
the standards and key steps for breastfeeding and/or the
provision of human milk to this group. More specific
guidance on the feeding of small, sick and/or preterm
newborns is available elsewhere (5, 50).
7
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
Some of the steps have been simplified in their application, Step 10 on post-discharge care focuses more on the
to ensure that they are feasible and applicable for all responsibilities of the facility providing maternity
facilities. To ensure that every infant who is born in and newborn services to plan for discharge and make
a facility has equitable access to the best quality of referrals, as well as to coordinate with and work to enhance
care, the steps must be within reach of every facility, community support for breastfeeding, rather than the
not just a select few. For example, step 2 on training specific creation of mother-to-mother support groups.
staff focuses more on competency assessment to ensure
that staff have the knowledge, competence and skills to
support breastfeeding, rather than insisting on a specific
curriculum. Step 5 on providing mothers with practical
The core intent
support on how to breastfeed does not emphasize one
type of milk expression, but focuses more on issues of
of the Ten Steps...
positioning, suckling, and ensuring the mother is prepared
for potential breastfeeding difficulties. is to protect,
Step 9 on the use of feeding bottles, teats and pacifiers promote and support
breastfeeding
now focuses on counselling mothers on their use, rather
than completely prohibiting them. The evidence for a
complete prohibition of their use was found to be weak,
since the systematic review conducted in the guideline
development process found little or no difference in
breastfeeding rates between healthy term infants who
used feeding bottles, teats or pacifiers in the immediate
postpartum period and those who did not (51). Among
preterm infants, the systematic reviews on non-nutritive
suckling did not find a difference in breastfeeding-related
outcomes and found a positive impact on the duration
of hospital stay (52, 53). For preterm infants, the use of
feeding bottles and teats is still discouraged.
1. a. Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health
Assembly resolutions.
b. Have a written infant feeding policy that is routinely communicated to staff and parents.
3. Discuss the importance and management of breastfeeding with pregnant women and their families.
4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding
as soon as possible after birth.
5. Support mothers to initiate and maintain breastfeeding and manage common difficulties.
6. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.
7. Enable mothers and their infants to remain together and to practise rooming-in 24 hours a day.
8. Support mothers to recognize and respond to their infants’ cues for feeding.
9. Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.
10. Coordinate discharge so that parents and their infants have timely access to ongoing support and care.
8
The Revised Baby-friendly Hospital Initiative 2018
Revision of the country-level The guidance also incorporates, or is aligned with, other
implementation guidance WHO or UNICEF technical guidance documents, including
This implementation guidance proposes a number of the Guidance on ending the inappropriate promotion of foods
revisions to the implementation of the BFHI, to facilitate for infants and young children (54), the 2016 WHO/UNICEF
nationwide scale-up and ensure sustainability over time. Guideline: updates on HIV and infant feeding (55), the WHO
The guidance focuses on integrating the protection, Standards for improving quality of maternal and newborn
promotion and support of breastfeeding more fully into care in health facilities (4) and the WHO Framework on
the health-care system, including in private and public integrated people-centred health services (56).
facilities. The modifications and increased feasibility
serve the purpose of increasing newborns’ access to
This updated guidance is aimed at strengthening the
breastfeeding in all facilities, not only a select few.
health system and proposes a less vertical management
and implementation structure, requiring fewer resources
dedicated specifically to the initiative. It aims to coordinate
The guidance focuses the strategies for integrated people-centred health
services (56) and strengthen the quality-improvement
on integrating… aspects already present in the BFHI.
more fully into the Box 2 summarizes the key updated directions for BFHI
implementation, as described in detail in section 3 and
health-care system section 4.
1. Appropriate care to protect, promote, and support breastfeeding is the responsibility of every facility providing
maternity and newborn services. This includes private facilities, as well as public ones, and large as well as
small facilities.
2. Countries need to establish national standards for the protection, promotion and support for breastfeeding
in all facilities providing maternity and newborn services, based on the updated Ten Steps to Successful
Breastfeeding and global criteria.
3. The Baby-friendly Hospital Initiative must be integrated with other initiatives for maternal and newborn health,
health-care improvement, health-systems strengthening and quality assurance.
4. To ensure that health-care providers have the competencies to implement the BFHI, this topic needs to be
integrated into pre-service training curricula. In addition, in-service training needs to be provided when
competencies are not yet met.
5. Public recognition of facilities that implement the Ten Steps and comply with the global criteria is one way to
incentivize quality improvement. Several other incentives exist, ranging from compliance with national facility
standards to performance-based financing.
6. Regular internal monitoring is a crucial element of both quality improvement and ongoing quality assurance.
7. External assessment is a valuable tool for validating the quality of maternity and newborn services. External
assessments should be sufficiently streamlined into existing mechanisms that can be implemented sustainably.
9
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
10
The Revised Baby-friendly Hospital Initiative 2018
In line with the WHO Framework on integrated people- Facilities providing maternity and newborn services need
centred health services (56), it is important to ensure that to comply with the Ten Steps. The 2018 version of the Ten
“all people have equal access to quality health services Steps is separated into critical management procedures,
that are co-produced in a way that meets their life course which provide an enabling environment for sustainable
needs and respects social preferences, are coordinated implementation within the facility, and key clinical
across the continuum of care, and are comprehensive, practices, which delineate the care that each mother
safe, effective, timely, efficient and acceptable; and all and infant should receive. The key clinical practices are
carers are motivated, skilled and operate in a supportive evidence-based interventions to support mothers to
environment”. A specific aspect of this is providing care successfully establish breastfeeding. The Ten Steps are
in a culturally appropriate manner, including providing outlined in Box 1 and described in detail in section 2.1
materials in languages that all clients understand. and section 2.2. The specific recommendations in the
new WHO Guideline: protecting, promoting and supporting
breastfeeding in facilities providing maternity and newborn
The Ten Steps do not encompass all aspects of quality
services (3) are also presented in the text, with the relevant
maternity and newborn care. “Mother-friendly” birthing
recommendation number added. Annex 1 shows how
and postnatal care practices have been identified that
the revised Ten Steps incorporate all of the new WHO
are important for the mother’s own well- being and
guidelines (3) and how they relate to the original Ten Steps.
the respect of her dignity and her rights (4). Many of
these “mother-friendly” practices also help to enable
breastfeeding (57). It is important that women are not While each of the Ten Steps contributes to improving the
submitted to unnecessary or harmful practices during support for breastfeeding, optimal impact on breastfeeding
labour, childbirth and the early postnatal period. practices, and thereby on maternal and child well-being,
Such practices include, but are not limited to, unnecessary is only achieved when all Ten Steps are implemented as a
(i.e. without a medical indication) use of the following: package. The text that follows should be read in this light.
episiotomy, instrumental vaginal childbirth and caesarean
section. Women should also be encouraged to adopt the
position of their choice during labour. In addition, women
and newborns must be treated with respect, with their
dignity maintained and their privacy respected; they must
not be subjected to mistreatment (58); and they must be
able to make informed decisions. Women also need to be
able to have a birth companion of their choice.
11
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
2.1. Critical management procedures to Implementation: The Code (25–27) lays out clear
support breastfeeding responsibilities of health-care systems to not promote
infant formula, feeding bottles or teats and to not be used
Facilities providing maternity and newborn services need by manufacturers and distributors of products under
to adopt and maintain four critical management procedures the scope of the Code for this purpose. This includes
to ensure universal and sustained application of the key the provision that all facilities providing maternity
clinical practices. The first three of these, application and newborn services must acquire any breast-milk
of the Code (25–27), development of written policies, substitutes, feeding bottles or teats they require through
and operation of monitoring and data-management normal procurement channels and not receive free
systems, are all part of the first step on facility policies. or subsidized supplies (WHA Resolution 39.28 (62)).
Step 2 deals with the need to ensure the capacity of all Furthermore, staff of facilities providing maternity
facility staff. and newborn services should not engage in any form of
promotion or permit the display of any type of advertising
of breast-milk substitutes, including the display or
Step 1: Facility policies distribution of any equipment or materials bearing the
The International Code of Marketing of Breast- milk
brand of manufacturers of breast-milk substitutes,
Substitutes and relevant World Health Assembly or discount coupons, and they should not give samples
resolutions (25–27) of infant formula to mothers to use in the facility or to
take home.
Step 1a: Comply fully with the International
Code of Marketing of Breast-milk Substitutes In line with the WHO Guidance on ending the inappropriate
and relevant World Health Assembly resolutions. promotion of foods for infants and young children, published
in 2016 and endorsed by the WHA (54), health workers
Rationale: Families are most vulnerable to the marketing and health systems should avoid conflicts of interest
of breast-milk substitutes during the entire prenatal, with companies that market foods for infants and young
perinatal and postnatal period when they are making children. Health- professional meetings should never be
decisions about infant feeding. The WHA has called sponsored by industry and industry should not participate
upon health workers and health-care systems to in parenting education.
comply with the International Code of Marketing of
Breast-milk Substitutes (25, 26) and subsequent relevant Global standards:
WHA resolutions (27) (the Code), in order to protect • All infant formula, feeding bottles and teats used
families from commercial pressures. Additionally, in the facility have been purchased through normal
health professionals themselves need protection from procurement channels and not received through free
commercial influences that could affect their professional or subsidized supplies.
activities and judgement. Compliance with the Code is
important for facilities providing maternity and newborn
• The facility has no display of products covered under
services, since the promotion of breast-milk substitutes is
the Code or items with logos of companies that produce
one of the largest undermining factors for breastfeeding
breast-milk substitutes, feeding bottles and teats,
(59). Companies marketing breast-milk substitutes,
or names of products covered under the Code.
feeding bottles and teats are repeatedly found to violate
the Code (60). It is expected that the sales of breast-milk
substitutes will continue to increase globally, which • The facility has a policy that describes how it abides
is detrimental for children’s survival and well-being by the Code, including procurement of breast-milk
(13, 61). This situation means that ongoing concerted substitutes, not accepting support or gifts from
efforts will be required to protect, promote and support producers or distributors of products covered by
breastfeeding, including in facilities providing maternity the Code and not giving samples of breast-milk
and newborn services. substitutes, feeding bottles or teats to mothers.
12
The Revised Baby-friendly Hospital Initiative 2018
Step 1b: Have a written infant Step 1c: Establish ongoing monitoring
feeding policy that is routinely and data-management systems.
communicated to staff and parents.
Rationale: Facilities providing maternity and newborn
Rationale: Policy drives practice. Health-care providers services need to integrate recording and monitoring
and institutions are required to follow established policies. of the clinical practices related to breastfeeding into
The clinical practices articulated in the Ten Steps need to their quality-improvement/monitoring systems (see
be incorporated into facility policies, to guarantee that section 2.4).
appropriate care is equitably provided to all mothers and
babies and is not dependent on the preferences of each Implementation: Recommended indicators for facility-
care provider. Written policies are the vehicle for ensuring based monitoring of the key clinical practices are listed
patients receive consistent, evidence-based care, and are in Appendix 1, Table 1. Two of the indicators, early
an essential tool for staff accountability. Policies help to initiation of breastfeeding and exclusive breastfeeding,
sustain practices over time and communicate a standard are considered “sentinel indicators”. All facilities should
set of expectations for all health workers. routinely track these indicators for each mother–infant
pair. Recording of information on these sentinel indicators
Implementation: Facilities providing maternity should be incorporated into the medical charts and
and newborn services should have a clearly written collated into relevant registers. The group or committee
breastfeeding policy that is routinely communicated that coordinates the BFHI- related activities within a
to staff and parents (recommendation 12). A facility facility needs to review progress at least every 6 months.
breastfeeding policy may stand alone as a separate During concentrated periods of quality improvement,
document, be included in a broader infant feeding monthly review is needed. The purpose of the review
policy, or be incorporated into a number of other policy is to continually track the values of these indicators,
documents. However organized, the policy should include to determine whether established targets are met, and,
guidance on how each of the clinical and care practices if not, plan and implement corrective actions. In addition,
should be implemented, to ensure that they are applied if the facility has an ongoing system of maternal discharge
consistently to all mothers. The policy should also spell out surveys for other quality-improvement/quality- assurance
how the management procedures should be implemented, assessments, and it is possible to add question(s), one or
preferably via specific processes that are institutionalized. both indicators could be added for additional verification
purposes or periodic checks.
Global standards:
• The health facility has a written infant feeding policy Additional process indicators for monitoring adherence
that addresses the implementation of all eight key to the key clinical practices are also recommended. These
clinical practices of the Ten Steps, Code implementation, indicators are particularly important during an active
and regular competency assessment. process of quality improvement and should be assessed
monthly during such a process. Once acceptable levels
• Observations in the facility confirm that a summary of compliance have been achieved, the frequency of data
of the policy is visible to pregnant women, mothers collection on these additional indicators can be reduced,
and their families. for example to annually. However, if the level of the
sentinel indicators falls below 80% (or below national
standards), it will be important to assess both the clinical
• A review of all clinical protocols or standards related to
practices and all management procedures, to determine
breastfeeding and infant feeding used by the maternity
where the bottlenecks are and what needs to be done to
services indicates that they are in line with BFHI
achieve the required standards.
standards and current evidence- based guidelines.
13
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
The recommended indicators do not cover all of the global It is recommended that a minimum of 20 mother– infant
standards listed above because of the need to keep the pairs be included for each indicator, each time the data
monitoring system as simple as possible. Countries or are reviewed, although small facilities may need to settle
individual facilities could include additional indicators for a smaller number if 20 pairs are not available.
where feasible. Two alternative methods for verification
are proposed – newborn registries and maternal discharge The global standards call for a minimum of 80%
surveys (which could be done in a written or oral way or compliance for all process and outcome indicators,
via a cell phone [SMS]). Facilities are not expected to use including early initiation of breastfeeding and exclusive
both methodologies at the same time. Depending on what breastfeeding. It is recognized that in contexts where
other monitoring systems facilities are using, either may many women choose not to breastfeed, these rates may
be more practical and feasible. be difficult to attain. Lower standards may need to be
set at the national or local level, with the expectation
The frequency of data collection will depend on the that they should be raised over time, as other aspects
method of verification. For example, if questions are of breastfeeding support in the community improve.
added to maternal discharge surveys that are already Each facility should attempt to regularly achieve at least
ongoing, the periodicity will, by default, be a function of 80% adherence on each indicator, and facilities that
the periodicity of the ongoing survey. If the information do not meet this target should focus on increasing the
is collected through newborn registries and the registries percentage over time.
are already being reviewed to collect data on the sentinel
outcome indicators, collection of data on the key clinical Global standards:
practices for all newborns is recommended. Alternatively, • The facility has a protocol for an ongoing monitoring
a sample of registries could be reviewed every 6 months and data-management system to comply with the
to collect this information, to reduce the burden of eight key clinical practices.
abstracting, summarizing and reviewing large amounts
of data from the registries. If a new system of maternal
• Clinical staff at the facility meet at least every 6 months
discharge surveys is put into place, a minimum periodicity
to review implementation of the system.
of every 6 months is needed. However, monitoring needs
to be streamlined and manageable within the facilities’
existing resources. Step 2: Staff competency
Thus, to the extent possible, it is best to not implement Step 2: Ensure that staff have sufficient
new methods of data collection, unless necessary or knowledge, competence and skills
for periodic purposes of verification. The same goes for to support breastfeeding.
the amount of data collected; more is not necessarily
better if systems are not in place to analyse and use the Rationale: Timely and appropriate care for breastfeeding
information to improve breastfeeding support. mothers can only be accomplished if staff have the
knowledge, competence and skills to carry it out. Training
For the key clinical practice indicators, monitoring is of health staff enables them to develop effective skills,
best if based on maternal report. Collection of data for give consistent messages, and implement policy standards.
some indicators could be done through electronic medical Staff cannot be expected to implement a practice or
records or from paper reports on each mother–infant educate a patient on a topic for which they have received
pair, but runs the risk that staff completing these records no training.
will over-report practices that they have been taught
they are supposed to do. Options for maternal data Implementation: Health-facility staff who provide infant
collection include: feeding services, including breastfeeding support, should
have sufficient knowledge, competence and skills to
• exit interviews with mothers (preferably by a person support women to breastfeed (recommendation 13).
not directly in charge of their care); In general, the responsibility for building this capacity
resides with the national pre-service education system.
• short paper questionnaires to mothers for confidential However, if staff capacity is deficient, facilities providing
completion upon discharge; maternity and newborn services will need to take
corrective measures to strengthen that capacity, such as
by offering courses at the facility or requiring that staff
• sending questions to the mother via SMS.
take courses elsewhere. While some material can be
taught through didactic lectures (including electronic
resources), some supervised clinical experience with
testing of competency is necessary. It is important to
focus not on a specific curriculum but on the knowledge
and skills obtained.
14
The Revised Baby-friendly Hospital Initiative 2018
All staff who help mothers with infant feeding should be Global standards:
assessed on their ability to: • At least 80% of health professionals who provide
antenatal, delivery and/or newborn care report they
have received pre-service or in-service training on
1. use listening and learning skills to counsel a mother;
breastfeeding during the previous 2 years.
4. assess a breastfeed;
• At least 80% of health professionals who provide
antenatal, delivery and/or newborn care are able
5. help a mother to position herself and her baby to correctly answer three out of four questions
for breastfeeding; on breastfeeding knowledge and skills to
support breastfeeding.
6. help a mother to attach her baby to the breast;
2.2. Key clinical practices to support
7. explain to a mother about the optimal pattern breastfeeding
of breastfeeding;
The updated BFHI highlights eight key clinical practices,
8. help a mother to express her breast milk; based on the WHO Guideline: protecting, promoting and
supporting breastfeeding in facilities providing maternity and
9. help a mother to cup feed her baby; newborn services (3), issued in 2017. These key practices
are discussed next.
11. help a mother who thinks she does not have Step 3: Discuss the importance and
enough milk; management of breastfeeding with
pregnant women and their families.
12. help a mother with a baby who cries frequently;
Rationale: All pregnant women must have basic
13. help a mother whose baby is refusing to breastfeed; information about breastfeeding, in order to make
informed decisions. A review of 18 qualitative studies
indicated that mothers generally feel that infant feeding
14. help a mother who has flat or inverted nipples;
is not discussed enough in the antenatal period and
that there is not enough discussion of what to expect
15. help a mother with engorged breasts; with breastfeeding (42). Mothers want more practical
information about breastfeeding. Pregnancy is a key time
16. help a mother with sore or cracked nipples; to inform women about the importance of breastfeeding,
support their decision- making and pave the way for
17. help a mother with mastitis; their understanding of the maternity care practices that
facilitate its success. Mothers also need to be informed
that birth practices have a significant impact on the
18. help a mother to breastfeed a low-birth-weight baby
establishment of breastfeeding.
or sick baby;
15
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
Implementation: Where facilities provide antenatal care, The information must be provided free of conflicts
pregnant women and their families should be counselled of interest. As stipulated in the Guidance on ending
about the benefits and management of breastfeeding inappropriate promotion of foods for infants and young
(recommendation 14). In many settings, antenatal care children (54), companies that market foods for infants and
is predominantly provided through primary health- young children should not “directly or indirectly provide
care clinics or community health workers. If facilities education to parents and other caregivers on infant and
providing maternity and newborn services do not have young child feeding in health facilities”.
direct authority over these care providers, they should
work with them to ensure that mothers and families are Women at increased risk for preterm delivery or birth
fully informed about the importance of breastfeeding and of a sick infant (e.g. pregnant adolescents, high-risk
know what to expect when they deliver at the facility. pregnancies, known congenital anomalies) must begin
In other cases, the facility directly provides antenatal care discussions with knowledgeable providers as soon as
services or offers classes for pregnant women. In this case, feasible concerning the special circumstances of feeding
provision of breastfeeding information and counselling a premature, low-birth-weight or sick baby (63).
is the direct responsibility of the facility.
Global standards:
Breastfeeding education should include information on • A protocol for antenatal discussion of breastfeeding
the importance of breastfeeding and the risks of giving includes at a minimum:
formula or other breast-milk substitutes, along with
national and health-professional recommendations
– the importance of breastfeeding;
for infant feeding. Practical skills such as positioning
and attachment, on-demand feeding, and recognizing
feeding cues are a necessary component of antenatal – global recommendations on exclusive breastfeeding
counselling. Families should be presented with up- to- for the first 6 months, the risks of giving formula
date information on best practices in facilities providing or other breast-milk substitutes, and the fact that
maternity and newborn services regarding skin-to-skin breastfeeding continues to be important after
contact, initiation of breastfeeding, supplementation 6 months when other foods are given;
protocols and rooming-in. Women also need to be
informed about possible challenges they might encounter – the importance of immediate and sustained skin-
(such as engorgement, or a perception of not producing to-skin contact;
enough milk) and how to address them.
– the importance of early initiation of breastfeeding;
Antenatal breastfeeding counselling must be tailored to the
individual needs of the woman and her family, addressing – the importance of rooming-in;
any concerns and questions they have. This counselling
needs to be sensitively given and consider the social and
– the basics of good positioning and attachment;
cultural context of each family.
16
The Revised Baby-friendly Hospital Initiative 2018
Step 4: Immediate postnatal care influence of anaesthesia or drugs will require closer
observation. When mothers are not fully awake and
Step 4: Facilitate immediate and responsive, a health professional, doula, friend or family
member should accompany the mother, to prevent the
uninterrupted skin-to-skin contact and
baby from being hurt accidentally.
support mothers to initiate breastfeeding
as soon as possible after birth.
Immediate skin-to-skin care and initiation of
breastfeeding is feasible following a caesarean section
Rationale: Immediate skin-to-skin contact and early
with local anaesthesia (epidural) (64). After a caesarean
initiation of breastfeeding are two closely linked
section with general anaesthesia, skin- to-skin contact
interventions that need to take place in tandem for optimal
and initiation of breastfeeding can begin when the mother
benefit. Immediate and uninterrupted skin- to-skin
is sufficiently alert to hold the infant. Mothers or infants
contact facilitates the newborn’s natural rooting reflex
who are medically unstable following delivery may need
that helps to imprint the behaviour of looking for the breast
to delay the initiation of breastfeeding. However, even if
and suckling at the breast. Additionally, immediate skin-
mothers are not able to initiate breastfeeding during the
to-skin contact helps populate the newborn’s microbiome
first hour after birth, they should still be supported to
and prevents hypothermia. Early suckling at the breast
provide skin- to-skin contact and to breastfeed as soon
will trigger the production of breast milk and accelerate
as they are able (65).
lactogenesis. Many mothers stop breastfeeding early or
believe they cannot breastfeed because of insufficient milk,
so establishment of a milk supply is critically important Skin-to-skin contact is particularly important for preterm
for success with breastfeeding. In addition, early initiation and low-birth-weight infants. Kangaroo mother care
of breastfeeding has been proven to reduce the risk of involves early, continuous and prolonged skin-to-
infant mortality (10). skin contact between the mother and the baby (66),
and should be used as the main mode of care as soon as
the baby is stable (defined as the absence of severe apnoea,
Implementation: Early and uninterrupted skin-to-
desaturation and bradycardia), owing to demonstrated
skin contact between mothers and infants should be
benefits in terms of survival, thermal protection and
facilitated and encouraged as soon as possible after birth
initiation of breastfeeding. The infant is generally firmly
(recommendation 1). Skin-to-skin contact is when the
held or supported on the mother’s chest, often between
infant is placed prone on the mother’s abdomen or chest
the breasts, with the mother in a semi-reclined and
with no clothing separating them. It is recommended that
supported position.
skin-to-skin contact begins immediately, regardless
of method of delivery. It should be uninterrupted for at
least 60 minutes. Preterm infants may be able to root, attach to the breast
and suckle from as early as 27 weeks’ gestation (67).
As long as the infant is stable, with no evidence of severe
Initiation of breastfeeding is typically a direct consequence
apnoea, desaturation or bradycardia, preterm infants can
of uninterrupted skin-to-skin contact, as it is a natural
start breastfeeding. However, early initiation of effective
behaviour for most babies to slowly squirm or crawl
breastfeeding may be difficult for these infants if the
toward the breast. Mothers may be supported to help the
suckling reflex is not yet established and/or the mother
baby to the breast if desired. Mothers should be helped in
has not yet begun plentiful milk secretion. Early and
understanding how to support the baby and how to make
frequent milk expression is critical to stimulating milk
sure the baby is able to attach and suckle at the breast.
production and secretion for preterm infants who are
All mothers should be supported to initiate breastfeeding
not yet able to suckle. Transition to direct and exclusive
as soon as possible after birth, within the first hour after
breastfeeding should be the aim whenever possible (50)
delivery (recommendation 2).
and is facilitated by prolonged skin- to-skin contact.
17
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
18
The Revised Baby-friendly Hospital Initiative 2018
19
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
• At least 80% of term breastfed babies who received Rooming-in may not be possible in circumstances when
supplemental feeds have a documented medical infants need to be moved for specialized medical care
indication for supplementation in their medical record. (recommendation 5). If preterm or sick infants need to
be in a separate room to allow for adequate treatment
• At least 80% of preterm babies and other vulnerable and observation, efforts must be made for the mother
newborns that cannot be fed their mother’s own milk to recuperate postpartum with her infant, or to have no
are fed with donor human milk. restrictions for visiting her infant. Mothers should have
adequate space to express milk adjacent to their infants.
20
The Revised Baby-friendly Hospital Initiative 2018
21
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
For preterm infants, evidence does demonstrate that use Printed and/or online information could be useful to
of feeding bottles with teats interferes with learning to provide contacts for support, in case of questions, doubts
suckle at the breast. If expressed breast milk or other or difficulties, but this should not substitute for active
feeds are medically indicated for preterm infants, feeding follow-up care by a skilled professional.
methods such as cups or spoons are preferable to feeding
bottles and teats (recommendation 11). On the other Facilities providing maternity and newborn services need
hand, for preterm infants who are unable to breastfeed to identify appropriate community resources for continued
directly, non-nutritive sucking and oral stimulation and consistent breastfeeding support that is culturally
may be beneficial until breastfeeding is established and socially sensitive to their needs. The facilities have a
(recommendation 9). Non-nutritive sucking or oral responsibility to engage with the surrounding community
stimulation involves the use of pacifiers, a gloved finger to enhance such resources. Community resources include
or a breast that is not yet producing milk. primary health-care centres, community health workers,
home visitors, breastfeeding clinics, nurses/midwives,
There should be no promotion of feeding bottles or teats lactation consultants, peer counsellors, mother-to-
in any part of facilities providing maternity and newborn mother support groups, or phone lines (“hot lines”).
services, or by any of the staff. As is the case with breast- The facility should maintain contact with the groups and
milk substitutes, these products fall within the scope of individuals providing the support as much as possible,
the Code (25–27). and invite them to the facility where feasible.
Global standards: Follow-up care is especially crucial for preterm and low-
• At least 80% of breastfeeding mothers of preterm and birth-weight babies. In these cases, the lack of a clear
term infants report that they have been taught about follow-up plan could lead to significant health hazards.
the risks of using feeding bottles, teats and pacifiers. Ongoing support from skilled professionals is needed.
22
The Revised Baby-friendly Hospital Initiative 2018
Plan
Study
Monitor progress
and learn
23
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
24
The Revised Baby-friendly Hospital Initiative 2018
2. Integrate the Ten Steps into relevant national policy documents and professional standards of care.
3. Ensure the competency of health professionals and managers in implementation of the Ten Steps.
4. Utilize external assessment systems to regularly evaluate adherence to the Ten Steps.
5. Develop and implement incentives for compliance and/or sanctions for non-compliance with the Ten Steps.
6. Provide technical assistance to facilities that are making changes to adopt the Ten Steps.
9. Identify and allocate sufficient resources to ensure the ongoing funding of the initiative.
External
assessment
Achieve Health
professional Incentives
Universal & sanctions
4
competency
Coverage building
3 5
National
Policies &
leadership &
2 6
professional Technical
assistance
standards coordination
1
of care to facilities
9 7
Sustain
Programme Financing
8 National
monitoring
Over Time
Communications
& advocacy
25
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
3.1. National leadership and It is recommended to have one clearly identified focal
coordination person for the protection, promotion and support of
breastfeeding in facilities providing maternity and
newborn services. This can either be a government
Establish or strengthen a national
staff member for whom this is part of their duties, or,
breastfeeding coordination body.
where needed and feasible, a person appointed only for
this task. In some countries, the focal person may be
Every country should have an active national coordination
the director of an NGO designated to serve as the BFHI
body that is responsible for breastfeeding in general and
coordinating organization.
the protection, promotion and support of breastfeeding,
specifically in facilities providing maternity and newborn
The coordination body needs to have terms of reference
services. The national breastfeeding coordination body
and a strategic plan with a scope of at least 5 years,
should be multisectoral and include representation from
with annual workplans. The national breastfeeding
government (including health and nutrition, financing
coordination body has overall responsibility to plan and
and social services), academia, professional organizations,
coordinate all the key functions of the national BFHI
NGOs and community-based organizations. Organizations
programme as described in Box 3, and ensure they fit
responsible for maternal and newborn care both within and
the national context.
outside of government need to be part of the breastfeeding
coordination body. Some countries have found utility in
including representation from consumer organizations 3.2. Policies and professional standards
or mothers’ groups, to ensure that the perspectives of of care
the target populations are considered.
Integrate the Ten Steps into relevant
Actors with a conflict of interest, particularly companies national policy documents and
that produce and/or market foods for infants and young professional standards of care.
children, or feeding bottles and teats, cannot be members
of the coordination body. The same applies to health Countries are encouraged to explore all possible
professionals, researchers and others who have received avenues for mandating the Baby-friendly standards so
funding from producers or distributors of products under that all mother–infant pairs can benefit from timely
the scope of the Code (25–27), or from their parent or evidence-based care and services appropriate to their
subsidiary companies. A conflict of interest is a set of needs. The strongest incentive for facilities providing
circumstances where the interests of the BFHI may be maternity and newborn services is often a governmental
unduly influenced by the conflicting interest of a partner mandate. Through legislation, regulation, accreditation
in a way that affects, or may reasonably be perceived to or certification, governments can require health-care
affect, the integrity, independence, credibility of and facilities to adhere to specific policies and procedures.
public trust in the BFHI in a given country, and its ability For example, legislation can require that all facilities have
to protect, promote and support breastfeeding in facilities a breastfeeding policy and prohibit them from accepting
providing maternity and newborn services. There is a risk donations of breast-milk substitutes. Facility accreditation
that the aforementioned pressure from the breast- milk can be made dependent on adherence to a full set of
substitutes industry will continue to be present and try clinical standards and specific management procedures.
to undermine BFHI efforts at different levels.
26
The Revised Baby-friendly Hospital Initiative 2018
The key clinical practices and global standards of the Pre-service training for all professions that will interact
revised Ten Steps should be written into the standards with pregnant women, deliveries and newborns needs to
of care for professional bodies. At a minimum, standards include adequate time and attention on breastfeeding,
for nursing, midwifery, family medicine, obstetrics, including on the Ten Steps, and should include theoretical
paediatrics, neonatology, dietetics and anaesthesiology as well as practical sessions. Since current pre-service
should be laid out as basics of care for all newborns. training on breastfeeding is inadequate in many countries,
The national protocols for feeding of infants of mothers new competency-based national curricula may need to
who are living with HIV, as well as protocols for the use be developed and their quality guaranteed. The WHO
of donated human milk, also need to be incorporated Model chapter for textbooks for medical students and allied
into these standards. In addition, the management health professionals is a useful basis (85). Curricula on
procedures of the revised Ten Steps need to be reflected breastfeeding need to include clinical and administrative
in relevant guidance documents for clinical professionals, practices related to the protection, promotion and support
and countries need to develop tools to measure whether of breastfeeding, as well as health-worker responsibilities
the standards of care are being met (see section 3.7). under the Code (25–27). It is understood that updating a
curriculum, especially in the case of national curricula,
A relevant guidance document for incorporating the key is often a lengthy process that involves many different
clinical practices into standards of care is Standards for stakeholders who are not usually involved in breastfeeding-
improving quality of maternal and newborn care in health related activities (such as the ministry of education
facilities (4). This document provides clear standards and and other government institutions where relevant,
has incorporated most of the Ten Steps. Several countries as well as individual institutions for higher learning
are already working to implement these standards in the and organizations that award professional credentials).
context of the Quality of Care initiative (84).
While pre-service training is a critical component of
It should be clear in the policies and standards of care that long-term change in maternity practices, all health
the protection, promotion and support of breastfeeding in professionals working with pregnant women, mothers
facilities providing maternity and newborn services need and infants already in practice also need to be educated
to be maintained and, where necessary, strengthened in on timely and appropriate care. Continuing education and
humanitarian settings. in-service training will be important until several batches
of newly trained professionals in all the professions and
technical areas involved have graduated. Where national
3.3. Health professional competency
guidance or national curricula for in-service training of
building health professionals exist, the clinical practices and the
Code (25–27) need to be incorporated in the curricula.
Ensure the competency of health This also ensures that each individual facility does not need
professionals and managers in to develop its own materials or procedures. Many countries
implementation of the Ten Steps. have adapted the 20-hour course of the 2009 BFHI
implementation guidance (86). WHO and UNICEF are in
At all levels of the health-care system, health professionals the process of revising the course, based on the updated
need to have adequate knowledge, competence and Ten Steps and Global Standards in this document and are
skills to implement globally recommended practices and also creating an Integrated IYCF [Infant and Young Child
procedures for the protection, promotion and support of Feeding] Counselling Training package.
breastfeeding in facilities providing maternity and newborn
services. Individual facilities have the responsibility for In-service training must be seen as a short-term solution
assessing competencies and ensuring that all of those to a problem, not an ongoing method of capacity-
who work at a facility have appropriate knowledge and development. On-the-job refresher training sessions
skills when these are found to be substandard. and continuing education are needed regularly and can
be done in a modular way so that they do not interfere too
Designated teaching staff with appropriate qualifications, much with the provision of services. Training needs to
education and experience, will need to be appointed be competency based, focusing on practical skills rather
to teach and, if necessary, adapt or develop the new than only on theoretical knowledge.
materials and curricula. This is an essential investment
for long‑term sustainable capacity-strengthening.
27
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
The teaching staff in all relevant schools and universities, 3.4. External assessment
as well as trainers engaged in in-service training and
continuing education, will need to be trained in the new Utilize external assessment systems to
materials. However, this is an essential investment for
regularly evaluate adherence to the Ten Steps.
long-term sustainable capacity-strengthening and an
important task of the national breastfeeding coordination
All facilities providing maternity and newborn services
body. Train-the- trainer approaches to create a large
are responsible for providing timely and appropriate care
cadre of BFHI experts across the country are likely to
for mothers and newborns, in line with the Baby- friendly
be a cost- effective strategy to disseminate in-depth
guidelines (32) and national evidence-based quality
information about the Ten Steps.
standards. As described above, facilities need to develop
internal monitoring mechanisms to ensure adherence
Many of the educational materials needed for appropriate
to quality standards. However, external assessment is
maternity and newborn care may be taught through
also critical for quality assurance. The primary purpose
electronic or online courses. This could be an efficient
of external assessment should be to facilitate technical
and low-cost means of education, also allowing health
assistance and correction of inappropriate practices.
professionals to learn at their own pace and review
The technical assistance is not necessarily provided by
information when they need to refresh their knowledge
the external assessors themselves. In some countries,
later on. Existing resources already exist in some countries
external assessors report back to a specific group, which
and could be shared. Health professionals need to be
then provides feedback to the facility.
granted study time to undertake self-study courses.
28
The Revised Baby-friendly Hospital Initiative 2018
29
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
Table 1. Options for incentivizing compliance with the standards of the Baby-friendly Hospital Initiative
Inclusion in Clear accountability Requires indicators that help Countries already using
performance ensure the sustainability of performance contracts
contracts appropriate facility practices (and
not only meeting a specific target)
Public reporting Might not Reliance on self- reporting could Countries in which
of quality need external be biased (although external spot public opinion is an
indicators and assessments with checks could improve quality) important driver of
outcomes specific frequency health-care delivery
Requires public understanding of
what practices and outcomes are
good
30
The Revised Baby-friendly Hospital Initiative 2018
31
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
• Focusing first on facilities that are most likely to Various data sources can be used for countries to assess
comply with the recommendations (e.g. facilities adherence to the Ten Steps:
previously designated as “Baby-friendly”, facilities
with a history of quality-improvement successes) • Household surveys, such as demographic and health
could provide early wins and demonstrate to other surveys, may be used to estimate the percentage
facilities the feasibility of the recommendations. of mothers whose maternity experiences adhere
to recommended standards. The Demographic and
• Large facilities are also an important early target Health Survey (90) already includes questions on early
because the health of a large number of mothers and initiation of breastfeeding, exclusive breastfeeding
babies can be improved with changes in only one during the facility stay, and skin- to-skin contact.
place. Also, large facilities often serve as a point of Client satisfaction surveys or exit interviews are
comparison for smaller facilities, so having optimal routinely conducted in many countries and could
practices in place at these facilities is helpful for also provide an opportunity to collect national data
scaling up. on selected aspects of maternity care.
• Targeting teaching hospitals may be particularly • Where facilities providing maternity and newborn
effective in ensuring that new health professionals services routinely report data to health management
are well grounded in the Ten Steps before they are information systems, the data collected at the facility
assigned to facilities throughout the country. level can be reported to the district, provincial or
national database. These reports can be used to
3.7. National monitoring document the overall percentage of babies experiencing
recommended care, or the percentage of facilities that
are meeting a given threshold for acceptable practices.
Monitor implementation of the initiative.
32
The Revised Baby-friendly Hospital Initiative 2018
33
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
34
The Revised Baby-friendly Hospital Initiative 2018
35
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
36
The Revised Baby-friendly Hospital Initiative 2018
5.1. Countries with a well-functioning Where “mother-friendly” criteria that go beyond the
national “Baby-friendly” hospital Ten Steps have been incorporated into the designation
designation programme criteria, these can remain in place, unless there is a reason
to update them.
This updated implementation guidance moves the BFHI
away from a traditional model that focused on facility While maintaining a designation programme, these
designation as a main outcome and driver of practice countries also need to work on integration of the Ten
changes. For those countries that currently have a well- Steps into national policies and quality-improvement and
functioning designation programme that is able to reach maternal and child health programmes, as described in
the majority of facilities providing maternity and newborn section 3. The responsibilities of a national breastfeeding
services nationwide, this new guidance should not be or BFHI coordinating body summarized in Box 3 are equally
viewed as a reason to discontinue a successful programme. applicable whether a country operates a designation
programme or not.
The coordinating bodies in the countries in this category
should develop a plan to incorporate the updated Ten 5.2. Countries without an active or
Steps into the national BFHI standards. A transition successful BFHI programme
plan is needed to indicate when facilities are expected to
adhere to the updated standards and to use the new tools. For countries where the BFHI is currently not
Facilities that have already been designated and those implemented, or where it has not been possible for
in the pipeline for designation will need to be granted “Baby-friendly” designation to reach a majority of
a reasonable amount of time to make changes to their facilities, it is recommended to focus on integration and
practices before the new standards become mandatory. institutionalization of the Ten Steps, with a quality-
The coordinating body will need to: improvement approach at facility level and a solid,
supportive policy environment and monitoring and
• revise public materials on the Ten Steps; accountability mechanisms. The activities in section 3
lay out priority actions to revitalize the BFHI in a
• revise training courses and materials; sustainable way. Staff and management of facilities that
were designated a while ago will need to be informed of
the policy changes and updated standards and about the
• develop or update materials to assist facilities with
actions to undertake to comply with these standards.
internal monitoring;
37
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
38
The Revised Baby-friendly Hospital Initiative 2018
Corresponding recommendations
from WHO Guideline: protecting,
promoting and supporting Ten Steps in Protecting,
breastfeeding in facilities providing promoting and supporting
Ten Steps to Successful maternity and newborn services breast-feeding: the special role
Breastfeeding – revised 2018 (2017) (3) of maternity services (1989) (23)
1b. Infant feeding policy: Have Recommendation 12: Facilities Step 1: Have a written
a written infant feeding policy providing maternity and newborn breastfeeding policy that is
that is routinely communicated services should have a clearly written routinely communicated to all
to staff and parents. breastfeeding policy that is routinely health-care staff.
communicated to staff and parents.
2. Staff competency: Ensure that Recommendation 13: Health- facility Step 2: Train all health-care
staff have sufficient knowledge, staff who provide infant feeding staff in the skills necessary to
competence and skills to support services, including breastfeeding implement this policy.
breastfeeding. support, should have sufficient
knowledge, competence and skills to
support women to breastfeed.
39
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
Corresponding recommendations
from WHO Guideline: protecting,
promoting and supporting Ten Steps in Protecting,
breastfeeding in facilities providing promoting and supporting
Ten Steps to Successful maternity and newborn services breast-feeding: the special role
Breastfeeding – revised 2018 (2017) (3) of maternity services (1989) (23)
4. Immediate postnatal care: Recommendation 1: Early and Step 4: Help mothers initiate
Facilitate immediate and uninterrupted skin-to-skin contact breastfeeding within a
uninterrupted skin-to-skin between mothers and infants should half‑hour of birth.
contact and support mothers to be facilitated and encouraged as soon
initiate breastfeeding as soon as as possible after birth.
possible after birth.
Recommendation 2: All mothers
should be supported to initiate
breastfeeding as soon as possible
after birth, within the first hour after
delivery.
40
The Revised Baby-friendly Hospital Initiative 2018
Corresponding recommendations
from WHO Guideline: protecting,
promoting and supporting Ten Steps in Protecting,
breastfeeding in facilities providing promoting and supporting
Ten Steps to Successful maternity and newborn services breast-feeding: the special role
Breastfeeding – revised 2018 (2017) (3) of maternity services (1989) (23)
9. Feeding bottles, teats and Recommendation 9: For preterm Step 9: Give no artificial
pacifiers: Counsel mothers on infants who are unable to breastfeed teats or pacifiers (also called
the use and risks of feeding directly, non-nutritive sucking and dummies or soothers) to
bottles, teats and pacifiers. oral stimulation may be beneficial breastfeeding infants.
until breastfeeding is established.
10. Care at discharge: Coordinate Recommendation 15: As part of Step 10: Foster the establishment
discharge so that parents and protecting, promoting and supporting of breastfeeding support groups
their infants have timely access breastfeeding, discharge from facilities and refer mothers to them on
to ongoing support and care. providing maternity and newborn discharge from the hospital
services should be planned for and or clinic.
coordinated, so that parents and their
infants have access to ongoing support
and appropriate care.
41
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
42
The Revised Baby-friendly Hospital Initiative 2018
1. Hospital policies • Not promoting infant formula, bottles or teats Hospital policies help make
• Making breastfeeding care standard practice sure that all mothers and
babies receive the best care
• Keeping track of support for breastfeeding
3. Antenatal care • Discussing the importance of breastfeeding for Most women are able to
babies and mothers breastfeed with the right
• Preparing women in how to feed their baby support
6. Supplementing • Giving only breast milk unless there are Giving babies formula in
medical reasons the hospital makes it hard
• Prioritizing donor human milk when a to get breastfeeding going
supplement is needed
• Helping mothers who want to formula feed do
so safely
7. Rooming-in • Letting mothers and babies stay together day and Mothers need to be near
night their babies to notice and
• Making sure that mothers of sick babies can stay respond to feeding cues
near their baby
8. Responsive feeding • Helping mothers know when their baby is Breastfeeding babies
hungry whenever they are ready
• Not limiting breastfeeding times helps everybody
9. Bottles, teats, • Counselling mothers about the use and risks of Everything that goes in the
and pacifiers feeding bottles and pacifiers baby’s mouth needs to be
clean
43
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
44
The Revised Baby-friendly Hospital Initiative 2018
Dr Ala Curteanu
Chief of Perinatology Department
Mother and Child Institute
Republic of Moldova
Dr Rukhsana Haider
Founder and Chair
Training & Assistance for Health & Nutrition (TAHN) Foundation
Bangladesh
Ms Randa Saadeh
Independent Consultant
Lebanon
Dr Isabella Sagoe-Moses
Deputy Director
Reproductive and Child Health, Ghana Health Service
Ghana
Ms Julie Stufkens
Executive Officer New Zealand Breastfeeding Alliance (NZBA)
New Zealand
45
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
46
The Revised Baby-friendly Hospital Initiative 2018
References
1. 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; http://apps.who.int/iris/handle/10665/65380, accessed 7 March 2018).
2. 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.
3. Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and
newborn services. Geneva: World Health Organization; 2017 (http://apps.who.int/iris/bitstre
am/10665/259386/1/9789241550086-eng.pdf?ua=1, accessed 7 March 2018).
4. Standards for improving quality of maternal and newborn care in health facilities. Geneva: World Health
Organization; 2016 (http://apps.who.int/iris/bitstream/10665/249155/1/9789241511216-eng.pdf?ua=1,
accessed 7 March 2018).
5. Guidelines on optimal feeding of low birth-weight infants in low- and middle-income countries. Geneva: World
Health Organization; 2011 (http://www.who.int/maternal_child_adolescent/ documents/9789241548366.
pdf?ua=1, accessed 7 March 2018).
6. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization;
2018 (http://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf, accessed 7 March 2018).
7. World Health Organization, United Nations Children’s Fund. Global strategy for infant and young child feeding.
Geneva: World Health Organization; 2003 (http://apps.who.int/iris/bitstream/10665/42590/1/9241562218.
pdf, accessed 7 March 2018).
8. United Nations Children’s Fund. UNICEF data: monitoring the situation of children and women. Access the
data: infant and young child feeding (http://data.unicef.org/topic/nutrition/infant-and-young-child- feeding/,
accessed 7 March 2018).
9. 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.
10. NEOVITA Study Group. Timing of initiation, patterns of breastfeeding, and infant survival: prospective analysis
of pooled data from three randomised trials. Lancet Glob Health. 2016;4(4):e266–75. doi:10.1016/ S2214-
109X(16)00040-1.
11. The optimal duration of exclusive breastfeeding. Report of an expert consultation Geneva, Switzerland,
28–30 March 2001. Geneva: World Health Organization; 2011 (WHO/NHD01.09, WHO/FCH/CAH/01.24; http://
apps.who.int/iris/bitstream/10665/67219/1/WHO_NHD_01.09.pdf?ua=1, accessed 7 March 2018).
12. Salmon L. Food security for infants and young children: an opportunity for breastfeeding policy? Int Breastfeed
J. 2015;10:7. doi:10.1186/s13006-015-0029-6.
13. Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC et al., The Lancet Breastfeeding
Series Group. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;387:491–
504. doi:10.1016/S0140-6736(15)01044-2.
14. Victora CG, Horta BL, Loret de Mola C, Quevedo L, Pinheiro RT, Gigante DP et al. Association between breastfeeding
and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from
Brazil. Lancet Glob Health. 2015;3:e199–e205. doi: 10.1016/S2214-109X(15)70002-1.
15. Colchero MA, Contreras-Loya D, Lopez-Gatell H, González de Cosío T. The costs of inadequate breastfeeding
of infants in Mexico. Am J Clin Nutr. 2015;101(3):579–86. doi:10.3945/ajcn.114.092775.
16. Bartick MC, Schwarz EB, Green BD, Jegier BJ, Reinhold AG, Colaizy TT et al. Suboptimal breastfeeding in the
United States: maternal and pediatric health outcomes and costs. Matern Child Nutr. 2016;13(1). doi:10.1111/
mcn.12366.
47
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
17. Cohen R, Mrtek MB, Mrtek RG. Comparison of maternal absenteeism and infant illness rates among breast-feeding
and formula-feeding women in two corporations. Am J Health Promot. 1995;10(2):148– 153. doi:10.4278/0890-
1171-10.2.148.
18. Dadhich JP, Smoth J, Iellamo A, Suleiman A. Report on carbon footprints due to milk formula: a study from
selected countries of the Asia- Pacific Region. Delhi: BPNI/IBFAN Asia; 2016 (http://ibfan.org/docs/Carbon-
Footprints-Due-to-Milk-Formula.pdf, accessed 7 March 2018).
19. Infant and young child feeding in emergencies. Operational guidance for emergency relief staff and programme
managers, version 3.0 Oxford: IFE Core Group; 2017 (http://www.ennonline.net/operationalguidance-v3-2017,
accessed 7 March 2018).
20. Joint statement by the UN Special Rapporteurs on the Right to Food, Right to Health, the Working Group
on Discrimination against Women in law and in practice, and the Committee on the Rights of the Child in
support of increased efforts to promote, support and protect breast-feeding. Geneva: United Nations Human
Rights Office of the High Commissioner; 2016 (http://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.
aspx?NewsID=20871, accessed 7 March 2018).
21. United Nations. Sustainable Develoment Goals: 17 goals to transform our world (http://www.un.org/
sustainabledevelopment/sustainable-development-goals/, accessed 7 March 2018).
22. United Nations Children’s Fund. UNICEF data: monitoring the situation of children and women. Joint UNICEF/
WHO database 2016 of skilled health personnel, based on population based national household survey data and
routine health systems (https://data.unicef.org/topic/maternal-health/delivery-care/#, accessed 7 March 2018).
23. Protecting, promoting and supporting breast-feeding: the special role of maternity services.
A joint WHO/UNICEF statement. Geneva: World Health Organization; 1989 (http://apps.who.int/iris/bitstre
am/10665/39679/1/9241561300.pdf, accessed 7 March 2018).
24. Innocenti Declaration on the protection, promotion and support of breastfeeding. New York: United
Nations Children’s Fund; 1991 (http://www.who.int/about/agenda/health_development/events/innocenti_
declaration_1990.pdf, accessed 7 September 2018).
25. International Code of Marketing of Breast-milk Substitutes. Geneva: World Health Organization; 1981 (http://
www.who.int/nutrition/publications/code_english.pdf, accessed 7 March 2018).
26. The International Code of Marketing of Breast-Milk Substitutes – 2017 update: frequently asked questions.
Geneva: World Health Organization; 2017 (http://apps.who.int/iris/bitstream/10665/254911/1/WHO-NMH-
NHD-17.1-eng.pdf?ua=1, accessed 7 March 2018).
28. Evidence for the ten steps to successful breastfeeding. Geneva: World Health Organization; 1998 (WHO/
CHD/98.9; http://apps.who.int/iris/bitstream/10665/43633/1/9241591544_eng.pdf, accessed 7 March 2018).
29. Resolution WHA47.5. Infant and young child nutrition. In: Forty-seventh World Health Assembly, Geneva,
2–12 May 1994. Resolutions and decisions, annexes. Geneva: World Health Organization; 1994 (http://www.
who.int/nutrition/topics/WHA47.5_iycn_en.pdf, accessed 7 March 2018).
30. Resolution WHA49.15. Infant and young child nutrition. In: Forty-ninth World Health Assembly, Geneva,
20–25 May 1996. Resolutions and decisions, annexes. Geneva: World Health Organization; 1996 (http://www.
who.int/nutrition/topics/WHA49.15_iycn_en.pdf, accessed 7 March 2018).
31. Innocenti Declaration 2005 on infant and young child feeding, 22 November 2005, Florence, Italy. Geneva:
United Nations Children’s Fund; 2005 (http://www.unicef.org/nutrition/files/innocenti2005m_FINAL_
ARTWORK_3_MAR.pdf, accessed 7 March 2018).
32. Baby-friendly Hospital Initiative: revised, updated and expanded for integrated care. Geneva: World Health
Organization and United Nations Children’s Fund; 2009 (http://apps.who.int/iris/handle/10665/43593,
accessed 7 March 2018).
48
The Revised Baby-friendly Hospital Initiative 2018
33. Resolution WHA65.6. Comprehensive implementation plan on maternal, infant and young child nutrition. In:
Sixty-fifth World Health Assembly, Geneva, 21–26 May 2012. Resolutions and decisions, annexes. Geneva:
World Health Organization; 2012:12–13 (WHA65/2012/REC/1; http://www.who.int/nutrition/topics/WHA65.6_
resolution_en.pdf, accessed 7 March 2018).
34. World Health Organization. Global targets 2025. To improve maternal, infant and young child nutrition (http://
www.who.int/nutrition/global-target-2025/en/, accessed 7 March 2018).
35. Food and Agriculture Organization of the United Nations, World Health Organization. Second International
Conference on Nutrition, Rome, 19–21 November 2014. Conference outcome document: framework for action.
Rome: Food and Agriculture Organization of the United Nations; 2014 (http://www.fao.org/3/a-mm215e.pdf,
accessed 7 March 2018).
36. Food and Agriculture Organization of the United Nations, World Health Organization. United Nations Decade
of Action on Nutrition 2016–2025. Frequently asked questions. Rome: Food and Agriculture Organization of
the United Nations; 2016 (http://www.fao.org/3/a-i6137e.pdf, accessed 7 March 2018).
37. Decision WHA68(14). Maternal, infant and young child nutrition: development of the core set of indicators. In:
Sixty-eighth World Health Assembly, Geneva, 18–26 May 2015. Resolutions and decisions, annexes. Geneva:
World Health Organization; 2015:94 (WHA68/2015/REC/1; http://apps.who.int/gb/ebwha/pdf_files/WHA68-
REC1/A68_R1_REC1-en.pdf, accessed 7 March 2018).
38. Indicators for the Global monitoring framework on maternal, infant and young child nutrition. Geneva: World
Health Organization; 2014 (http://www.who.int/nutrition/topics/indicators_monitoringframework_miycn_
background.pdf?ua=1, accessed 7 March 2018).
39. Labbok MH. Global Baby-friendly Hospital Initiative monitoring data: update and discussion. Breastfeed Med.
2012;7:210–22. doi:10.1089/bfm.2012.0066.
40. National implementation of the Baby-friendly Hospital Initiative. Geneva: World Health Organization;
2017 (http://apps.who.int/iris/bitstream/10665/255197/1/9789241512381-eng.pdf?ua=1, accessed 7 March 2018).
41. Kramer MS, Chalmers B, Hodnett ED, Sevkovskaya Z, Dzikovich I, Shapiro S et al. Promotion of Breastfeeding
Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus. JAMA. 2001;285:413–20.
42. Pérez-Escamilla R, Martinez JL, Segura-Pérez S. Impact of the Baby-friendly Hospital Initiative on breastfeeding
and child health outcomes: a systematic review. Matern Child Nutr. 2016;12(3):402–17. doi:10.1111/mcn.12294.
43. DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity-care practices on breastfeeding. Pediatrics.
2008;122(Suppl. 2):S43–9. doi:10.1542/peds.2008-1315e.
44. Saadeh RJ. The Baby-Friendly Hospital Initiative (BFHI) 20 years on: facts, progress and the way forward.
J Hum Lact. 2012. doi:10.1177/0890334412446690.
45. Munn AC, Newman SD, Mueller M, Phillips SM, Taylor SN. The impact in the United States of the Baby-Friendly
Hospital Initiative on early infant health and breastfeeding outcomes. Breastfeed Med. 2016;11:222–30. doi:0.1089/
bfm.2015.0135.
46. United Nations Children’s Fund, World Health Organization. Country experiences with the Baby-friendly
Hospital Initiative: Compendium of case studies from around the world. New York: United Nations Children’s
Fund; 2017 (https://www.unicef.org/nutrition/files/BFHI_Case_Studies_FINAL.pdf, accessed 7 March 2018).
47. Pan American Health Organization, World Health Organization Regional Office for the Americas. The Baby
Friendly Hospital Initiative in Latin America and the Caribbean: current status, challenges, and opportunities.
Washington (DC): Pan American Health Organization; 2016 (http://iris.paho.org/xmlui/bitstream/
handle/123456789/18830/9789275118771_eng.pdf?sequence=1&isAllowed=y, accessed 7 March 2018).
48. WHO handbook for guideline development, 2nd ed. Geneva: World Health Organization; 2014 (http://apps.
who.int/medicinedocs/documents/s22083en/s22083en.pdf, accessed 7 March 2018).
49
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
49. World Health Organization, United Nations Children’s Fund. Baby-friendly Hospital Initiative Congress:
24–26 October 2016. Geneva: World Health Organization; 2016 (http://www.who.int/nutrition/events/2016_
bfhi_congress_24to26oct/en/, accessed 7 March 2018).
50. Nyqvist KH, Maastrup R, Hansen MN, Haggkvist AP, Hannula L, Ezeonodo A et al. Neo-BFHI: the Baby- friendly
Hospital Initiative for neonatal wards. Three guiding principles and Ten Steps to protect, promote and support
breastfeeding. Core document with recommended standards and criteria. Nordic and Quebec Working Group;
2015 (http://www.ilca.org/main/learning/resources/neo-bfhi, accessed 7 March 2018).
51. Jaafar SH, Ho JJ, Jahanfar S, Angolkar M. Effect of restricted pacifier use in breastfeeding term infants for
increasing duration of breastfeeding. Cochrane Database Syst Rev. 2016(8):CD007202. doi:10.1002/14651858.
CD007202.pub4.
52. Foster JP, Psaila K, Patterson T. Non-nutritive sucking for increasing physiologic stability and nutrition in
preterm infants. Cochrane Database Syst Rev. 2016;(10):CD001071. doi:10.1002/14651858.CD001071.pub3.
53. Greene Z, O’Donnell CP, Walshe M. Oral stimulation for promoting oral feeding in preterm infants. Cochrane
Database Syst Rev. 2016;(9):CD009720. doi:10.1002/14651858.CD009720.pub2.
54. Maternal, infant and young child feeding. Guidance on ending the inappropriate promotion of foods for infants
and young children. In: Sixty-ninth World Health Assembly, Geneva, 23–28 May 2016. Provisional agenda
item 12.1. Geneva: World Health Organization; 2016 (A69/7 Add 1; http://apps.who.int/gb/ebwha/pdf_files/
WHA69/A69_7Add1-en.pdf?ua=1, accessed 7 March 2018).
55. World Health Organization, United Nations Children’s Fund. Guideline: updates on HIV and infant feeding.
The duration of breastfeeding and support from health services to improve feeding practices among
mothers living with HIV. Geneva: World Health Organization; 2016 (http://apps.who.int/iris/bitstre
am/10665/246260/1/9789241549707-eng.pdf, accessed 7 March 2018).
56. Framework on integrated people-centred health services. In: Sixty-ninth World Health Assembly, Geneva,
23–28 May 2016. Provisional agenda item 16.1. Geneva: World Health Organization; 2016 (http://apps.who.
int/gb/ebwha/pdf_files/WHA69/A69_39-en.pdf?ua=1&ua=1, accessed 7 March 2018).
57. Smith LJ, Kroeger M. Impact of birthing practices on breastfeeding, 2nd ed. Sudbury: Jones and Bartlett; 2010.
58. The prevention and elimination of disrespect and abuse during facility-based childbirth. Geneva: World
Health Organization; 2015. (http://apps.who.int/iris/bitstream/10665/134588/1/WHO_RHR_14.23_eng.
pdf?ua=1&ua=1&ua=1, accessed 7 March 2018).
59. Piwoz E Huffmann S. The impact of marketing of breast-milk substitutes on WHO-recommended breastfeeding
practices. Food Nutr Bull. 2015;36:373–86. doi:10.1177/0379572115602174.
60. Breaking the rules stretching the rules 2014. Evidence of violations of the International Code of Marketing of
Breastmilk Substitutes and subsequent resolutions compiled from January 2011 to December 2013. Penang:
International Baby Food Action Network International Code Documentation Centre; 2014 (http://www.
ibfan-icdc.org/wp-content/uploads/2017/03/1__Preliminary_pages_5-2-2014.pdf, accessed 7 March 2018
[Executive summary]).
61. Baker P, Smith J, Salmon L, Friel S, Kent G, Iellamo A et al. Global trends and patterns of commercial milk-
based formula sales: is an unprecedented infant and young child feeding transition underway? Public Health
Nutr. 2016;19(14):2540–50. doi:10.1017/S1368980016001117.
62. Resolution 39.28. Infant and young child feeding. In: Thirty-ninth World Health Assembly, Geneva, 5–16 May
1986. Resolutions and decisions, annexes. Geneva: World Health Organization; 1986 (http://www.who.int/
nutrition/topics/WHA39.28_iycn_en.pdf?ua=1, accessed 7 March 2018).
63. US Department of Health and Human Services National Institutes of Health. What are the risk factors for
preterm labor and birth? (https://www.nichd.nih.gov/health/topics/preterm/conditioninfo/Pages/who_risk.
aspx, accessed 7 March 2018).
50
The Revised Baby-friendly Hospital Initiative 2018
64. Stevens J, Schmied V, Burns E, Dahlen H. Immediate or early skin-to-skin contact after a Caesarean section:
a review of the literature. Matern Child Nutr. 2014;10:456–73. doi:10.1111/mcn.12128.
65. Implications of cesarean delivery for breastfeeding outcomes and strategies to support breastfeeding.
Washington (DC): Alive & Thrive; 2014 (A&T Technical Brief Issue 8, February 2014; http://aliveandthrive.
org/wp-content/uploads/2014/11/Insight-Issue-8-Cesarean-Delivery-English.pdf, accessed 7 March 2018).
66. Kangaroo mother care: a practical guide. Geneva: World Health Organization; 2003 (http://apps.who.int/iris/
bitstream/10665/42587/1/9241590351.pdf, accessed 7 March 2018).
67. Nyqvist KH, Sjoden PO, Ewald U. The development of preterm infants’ breastfeeding behavior. Early Hum
Dev. 1999;55(3):247–64.
68. McFadden A, Gavine A, Renfrew MJ, Wade A, Buchanan P, Taylor JL et al. Support for healthy breastfeeding mothers
with healthy term babies. Cochrane Database Syst Rev. 2017;(2):CD001141. doi:10.1002/14651858. CD001141.pub5.
69. Meier PP, Furman LM, Degenhardt M. Increased lactation risk for late preterm infants and mothers: evidence
and management strategies to protect breastfeeding. J Midwifery Womens Health. 2007;52(6):579–87.
70. Becker GE, Smith HA, Cooney F. Methods of milk expression for lactating women. Cochrane Database Syst
Rev. 2016;(9):CD006170. doi:10.1002/14651858.CD006170.pub5.
71. Salvatori G, Guaraldi F. Effect of breast and formula feeding on gut microbiota shaping in newborns. Front
Cell Infect Microbiol. 2012;2:94. doi:10.3389/fcimb.2012.00094.
72. World Health Organization, United Nations Children’s Fund. Acceptable medical reasons for use of breast-
milk substitutes. Geneva: World Health Organization; 2009. (WHO/NMH/NHD?09.1, WHO/FCH/CAH/09.1;
http://apps.who.int/iris/bitstream/10665/69938/1/WHO_FCH_CAH_09.01_eng.pdf, accessed 7 March 2018).
73. Kellams A, Harrel C, Omage S, Gregory C, Rosen-Carole C, Academy of Breastfeeding Medicine. ABM Clinical
Protocol #3: Supplementary feedings in the healthy term breastfed neonate, revised 2017. Breastfeed Med.
2017;12)188–98. doi:10.1089/bfm.2017.29038.ajk.
74. World Health Organization, Food and Agriculture Organization of the United Nations. Safe preparation, storage
and handling of powdered infant formula: guidelines. Geneva: World Health Organization; 2007 (http://www.
who.int/foodsafety/publications/micro/pif_guidelines.pdf, accessed 7 March 2018).
75. DeMarchis A, Israel-Ballard K, Mansen KA, Engmann C. Establishing an integrated human milk banking
approach to strengthen newborn care. J Perinatol. 2017;37(5):469–74. doi:10.1038/jp.2016.198.
76. Bu’Lock F, Woolridge MW, Baum JD. Development of co-ordination of sucking, swallowing and breathing:
ultrasound study of term and preterm infants. Dev Med Child Neurol. 1990;32:669–78.
77. Woolridge MW. Problems of establishing lactation. Food Nutr Bull. 1996;17(4):316–23.
78. Improving the quality of hospital care for mothers and newborns: coaching manual. POCQI: point-of-care
quality improvement. New Delhi: World Health Organization Regional Office for South-East Asia; 2017 (http://
apps.who.int/iris/bitstream/10665/255876/1/9789290225485-eng.pdf, accessed 7 March 2018).
79. Quality improvement. Rockville (MD): US Department of Health and Human Services Health Resources and
Service Administration; 2011 (https://www.hrsa.gov/quality/toolbox/508pdfs/qualityimprovement.pdf,
accessed 7 March 2018).
80. Improving the quality of hospital care for mothers and newborns: learner manual. POCQI: point-of-care quality
improvement. New Delhi: World Health Organization Regional Office for South-East Asia; 2017 (https://www.
newbornwhocc.org/POCQI-Learner-Manual.pdf, accessed 7 March 2018).
51
Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services
82. Institute for Healthcare Improvement. Quality Improvement Essentials Toolkit (http://www.ihi.org/resources/
Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx, accessed 7 March 2018).
83. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies.
Geneva: World Health Organization; 2010 (http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_
full_web.pdf?ua=1, accessed 7 March 2018).
84. Quality, Equity, Dignity. A network for improving quality of care for maternal, newborn and child health. Quality
of care (http://www.qualityofcarenetwork.org/network-improve-qoc, accessed 7 March 2018).
85. Infant and young child feeding. Model chapter for textbooks for medical students and allied health
professionals. Geneva: World Health Organization; 2009 (http://www.who.int/maternal_child_adolescent/
documents/9789241597494/en/, accessed 7 March 2018).
86. Baby-friendly Hospital Initiative: revised updated and expanded for integrated care. Section 3: breastfeeding
promotion and support in a Baby-friendly hospital. A 20-hour course for maternity staff. Geneva: World
Health Organization and United Nations Children’s Fund; 2009. (http://www.who.int/nutrition/publications/
infantfeeding/bfhi_trainingcourse_s3/en/, accessed 7 March 2018).
87. Baird C. Top healthcare stories for 2016: pay-for-performance. Arlington (VA): Committee for Economic
Development; 2016 (https://www.ced.org/blog/entry/top-healthcare-stories-for-2016-pay-for-performance,
accessed 7 March 2018).
88. Cashin C, Chi YL, Smith P, Borowitz M, Thomson S, editors. Paying for performance in healthcare: Implications
for health system performance and accountability. Maidenhead: Open University Press, McGraw-Hill Education;
2014 (http://www.euro.who.int/__data/assets/pdf_file/0020/271073/Paying-for-Performance-in-Health-
Care.pdf, accessed 7 March 2018).
89. The Breakthrough Series: IHI’s collaborative model for achieving breakthrough improvement. IHI Innovation
Series white paper. Boston: Institute for Healthcare Improvement; 2003 (http://www.ihi.org/resources/Pages/
IHIWhitePapers/TheBreakthroughSeriesIHIsCollaborativeModelforAchievingBreakthroughImprovement.
aspx, accessed 7 March 2018).
90. DHS Program. Demographic and Health Surveys: Model Woman’s Questionnaire. Rockville (MD): DHS Program;
2017 (https://dhsprogram.com/pubs/pdf/DHSQ7/DHS7-Womans-QRE-EN-07Jun2017-DHSQ7.pdf, accessed
7 March 2018).
91. United Nations Children’s Fund, World Health Organization, 1000 Days, Alive & Thrive. Nurturing the health
and wealth of nations: the investment case for breastfeeding. New York and Geneva: United Nations Children’s
Fund and World Health Organization; 2017 (http://www.who.int/nutrition/publications/infantfeeding/global-
bf-collective-investmentcase.pdf?ua=1, accessed 7 March 2018).
92. Sinha B, Chowdhury R, Sankar M, Martines J, Teneja S, Mazumder S et al. Interventions to improve breastfeeding
outcomes: systematic review and meta analysis. Acta Paediatr. 2015;104:114–34. doi:10.1111/ apa.13127.
93. United Nations Children’s Fund. The Global Breastfeeding Collective (https://www.unicef.org/nutrition/
index_98470.html, accessed 7 March 2018).
52
For more information, please contact:
Department of Nutrition for Health and Development
World Health Organization
Avenue Appia 20
CH-1211 Geneva 27
Switzerland
Email: [email protected]
www.who.int/nutrition
ISBN 978-92-4-151380-7