Statement from BFUSA and Others Regarding Revised BFHI Guidance

Dear Colleagues,

After months of thoughtful and productive discussion with our five global breastfeeding promotion organizations, on April 11, 2018, the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) released the final version of the Implementation Guidance: Protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-friendly Hospital Initiative 2018. The final document is highly responsive to the recommendations made by our organizations, and we congratulate the WHO and UNICEF on a successful launch.

We strongly agree with the WHO and UNICEF that “Breastfeeding is a vital component of realizing every child’s right to the highest attainable standard of health, while respecting every mother’s right to make an informed decision about how to feed her baby, based on complete, evidence-based information, free from commercial interests, and the necessary support to enable her to carry out her decision.”

We also concur that “the first few hours and days of a newborn’s life are a critical window for establishing lactation and providing mothers with the support they need to breastfeed successfully” and that the “core purpose of the Baby-Friendly Hospital Initiative (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.”

We applaud the full application of the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly Resolutions (the International Code), comprehensive, evidence-based infant feeding policies and ongoing internal monitoring of adherence to relevant clinical practices being incorporated into Step One.

We stand united with the WHO and UNICEF on the goal of scaling up to universal BFHI coverage and ensuring its sustainability over time.

BACKGROUND

Motivated by deep concerns about the uneven and relatively low global adoption of the BFHI, the WHO and UNICEF undertook the important tasks of evaluating the strengths and weaknesses of the initiative and charting a course to revitalize both the overall initiative and the global standards.  It was an enormous undertaking.

An initial draft of their new proposed approach was released for public comment on October 11, 2017.  Our five organizations came together and, at the invitation of the WHO and UNICEF, shared our collective expertise and worked with them to recommend changes in some areas that were not fully addressed in the proposal and further develop the guidance.

We would like to thank the WHO and UNICEF for their openness and willingness to engage in discussions and undertake the extra effort required to incorporate our recommendations.  During the 6-month period of meetings, all parties worked together with the mutual goal of strengthening the guidance to empower countries to scale up to universal adoption.

HIGHLIGHTS OF KEY HIGH-LEVEL RECOMMENDATIONS

• Governments should become involved in the national implementation of the BFHI and should undertake efforts to integrate international standards into national systems.
• Professional organizations responsible for pre-service education should incorporate the evidence and practices embodied in the Ten Steps to Successful Breastfeeding (the Ten Steps) into their curricula.
• Efforts should be undertaken to draw public attention to the importance of breastfeeding, the risks of formulas and the practices that will help to protect, promote and support breastfeeding.
• Efforts should be undertaken to protect breastfeeding, families and staff from commercial marketing and unethical pressures.
• BFHI should be integrated into other interventions, existing international and/or national programs, and coordinated with efforts to support breastfeeding in communities and the workplace.
• For those countries that currently have a well-functioning designation program able to reach the majority of facilities providing maternity and newborn services nationwide, this new guidance should not be viewed as a reason to discontinue a successful program.

HIGHLIGHTS OF KEY COMPONENTS OF THE GUIDANCE

• Stresses the importance of exclusive breastfeeding for 6 months to provide the nurturing, nutrients and energy needed for physical and neurological growth and development.
• Includes a clear set of global criteria, with the option to tailor for applicability to national standards.
• Retains the Ten Steps in their original order and subject matter.  Includes wording changes that are more generalized and designed to allow for the future incorporation of new and/or updated evidence.  Explains the intent of each of the steps and offers clear guidance for their implementation.
• Acknowledges the contribution of each of the Ten Steps to improving the support for breastfeeding, and stresses the need for all Ten Steps to be implemented as a package in order to attain an optimal impact on breastfeeding practices.
• Provides updated guidance for the safe implementation of practices and monitoring of patients. Reminds health care providers of the importance of individualized attention and care.
• Describes the importance of mother-friendly birth practices and the impact of birth practices on breastfeeding. Stresses the importance of healthcare professionals being knowledgeable about those practices and their responsibility for educating mothers.  Refers them to other WHO guidelines for more details on the specific practices.
• Stresses the importance of breastfeeding and/or breast milk feeding for all infants cared for in a facility by including some guidelines, indicators and standards for providing breastfeeding support for preterm infants in addition to the guidelines, indicators and standards that have been traditionally included for healthy term infants.
• Sets a mandate for the evidence and practices embodied in the Ten Steps to be included in health care pre-service curricula while retaining the need to continue with in-service education until this is accomplished and several classes have graduated and entered into practice.
• Explains the responsibility of health care facilities and professionals for implementing the International Code and places it prominently in Step 1, setting the stage for the International Code to be embodied in all aspects of patient care.
• Stresses the importance of and proposes systems for monitoring and sustaining the practices.
• Provides clearly defined indicators that are easy to assess and will allow for comparisons between countries.  Retains all indicators at the 80% level.
• Acknowledges the importance of public recognition, such as accreditation, as a key driver for change.  Points to the need for external evaluation or assessment as one of the key principles of quality improvement and acknowledges the process of becoming Baby-friendly as transformative, with impacts pertaining to the entire environment around infant feeding.  This included the care being more patient centered; staff attitudes and skill levels about infant feeding improving dramatically; the use of infant formula and newborn nurseries being significantly reduced. States that the quality of care for breastfeeding clearly improved in facilities designated as “Baby-friendly.”
• Offers robust guidance for additional quality improvement options for countries where the traditional accreditation options are beyond reach.
• Reinforces the role of facilities providing maternity and newborn services of identifying appropriate community resources for continued and consistent breastfeeding support that is culturally and socially sensitive to the needs of families. Reminds facilities they have a responsibility to engage with the surrounding community to enhance such resources.

CALL TO ACTION

Given the responsiveness of this document to the concerns raised around the initial 2017 draft, we now call upon all those working with families on infant and young child feeding to band together, support its goals, and work within your countries to implement it in the most effective manner.

NEXT STEPS

We are working to ensure that a provision is included in a resolution for the upcoming WHA to request the Director General of WHO to work in collaboration with UNICEF to develop tools for training, monitoring, and advocacy on the Baby-Friendly Hospital Initiative to assist Member States with implementation.  We will continue to monitor the progress of the resolution, the development of tools and implementation of the BFHI guidance.

Thank you.

Sincerely,

Trish MacEnroe
Coordinator
Baby-Friendly Hospital Initiative Network of Industrialized Nations, Central and Eastern European Nations and Independent States (BFHI Network)

Elisabeth Sterken
Co-chair IBFAN Global Council
International Baby Food Action Network (IBFAN)

Michele Griswold
President
International Lactation Consultant Association (ILCA)

Ann Calandro
Chair
La Leche League International (LLLI)

Felicity Savage
Chairperson
World Alliance for Breastfeeding Action (WABA)