Short report on the Baby-Friendly Hospital Initiative Congress

Submitted on Behalf of the World Alliance for Breastfeeding Action (WABA) and the Academy of Breastfeeding Medicine (ABM)

Dr Felicity Savage, FABM, Chair of WABA.

Dr Rukhsana Haider, FABM, Co-Chair of WABA.

Introduction

The Baby-Friendly Hospital Initiative (BFHI) was launched in 1991 by WHO and UNICEF, with the aim of protecting, promoting and supporting breastfeeding in maternity facilities worldwide.  To be designated “Baby-Friendly”, facilities are required to follow the Ten Steps to Successful Breastfeeding and the Code of Marketing of Breastmilk Substitutes.

Since 1991, great progress has been made, and 20,000 maternity facilities world-wide have been designated Baby-Friendly. However, in the last decade, progress has slowed down, and the total number of designated facilities still represents less than one third of all maternities in the world. Also it has been difficult to maintain the necessary standards as the BFHI assessment procedure often lies outside normal hospital accreditation processes.

The 25^th Anniversary of the launch of the BFHI seemed an appropriate time to review progress and consider the need for the development of revised or new guidelines.

The purpose of the Congress accordingly was to:

• Celebrate achievements in improving quality of care for breastfeeding mothers
• Examine the current status of the Baby-Friendly Hospital Initiative
• Discuss new guidance on country implementation of the initiative
• Form regional networks to improve country programmes in maternity facilities.

Congress proceedings

Over 300 participants attended, including representatives from Ministries of Health of 133 countries, and from 17 international organisations.

Day 1.

The opening had moving tributes to late Dr Audrey Naylor, and late Dr Miriam Labbok, both of whom had made major contributions to the development and implementation of the BFHI. There followed presentations on the latest evidence for the importance of breastfeeding, the history of the BFHI, country experiences, and the status of the BFHI in different regions.

An “Introduction to the updated guidance on protection, promotion and support of breastfeeding in maternity facilities” was presented by  Dr Laurence Grummer-Strawn. An update has become necessary because:

– there is clear evidence that implementing the Ten Steps increases breastfeeding rates, with a dose response relationship – the more steps that are followed, the less breastfeeding rates decline in the early weeks;

– yet there are serious challenges, including the voluntary nature of the BFHI, the question of ownership, and the costs and workload of training and assessment;

– the existing guidelines were developed in 2006-7, and WHO now has a new process for the development of guidelines, which includes detailed reviews of their evidence base.

The scope of the new guidelines will be for maternity facilities only, and will cover preterm and low birth weight infants.

They will comprise:

– Guidelines on patient care: the process will be governed by the WHO Guidelines Review Committee, and developed by a Guidelines Development Group, with the inputs of 21 systematic reviews.

The Ten Steps will be discussed in November, and conclusions released in mid-late 2017.

– Implementation guidance for national programmes:  this will be developed by an External Review Group, from case studies, key-informant interviews, a global survey and other key documents.

The principles driving the changes will be:

– integrated people centred health services

– improving quality of care

– strengthening of health systems

Key points are:

• the BFHI should be the responsibility of every maternity facility, private and public, with countries establishing national standards of care;
• it should be integrated with other health care improvements and quality insurance initiatives;
• incentives to implement practices should be other than achieving designation;
• regular internal monitoring of practices is crucial;
• external assessment may still be required, but should be manageable with existing resources

Days 2 and 3.

A presentation on the Application of the Code in the BFHI, and a panel discussion on Capacity Building were included.

Much of the time was devoted to four presentations of Draft Updated Operational Guidance Topics for Implementation, each followed by discussion in 9 working groups, which were reported back in plenary sessions.

The Guidance Topics were:

–  1: Implementation in maternity facilities

–  2: Setting national health care standards

–  3: National implementation

–  4: National leadership and co-ordination

Reports from the 9 groups were extensive and varied and will be further discussed by the External Review Group in subsequent meetings, and considered in the development of new Guidance.

A summary of the discussions included the following key points:

• Breastfeeding is the norm and needs to be mainstreamed – it is not a special extra;
• The BFHI should be mainstreamed into other initiatives and policy and standards of care throughout a country;
• There is a need for strong advocacy for both breastfeeding in general, and the BFHI;
• Healthy and low birth weight babies must both be included in the initiative;
• The public and private system must be involved;
• The Code must be strong;
• Mother friendly practices and the mother friendly community need to be linked in to the BFHI;
• Training needs to be stronger with follow-up mechanisms, including supervision;

Operationalising, and the designation process are likely to be a challenge:

– government should be involved, but can sometimes  be a barrier;

– branding needs to be considered – and may require reconsideration of the title;

– new guidelines may make new issues apparent;

– electronic systems may be useful for evaluation.

The following simple recommendations were given to countries for proceeding while awaiting the new guidance and guidelines:

• If your BFHI is already strong: carry on with what you are doing;
• If you are struggling: try to work with networks such as professional associations and see if they can help move the initiative forward;
• If the BFHI is controversial for you: it may be best to wait for the new guidelines. These may become available in late 2017.

Regional meetings were then held to discuss the development of regional networks to support implementation, followed by a closing session.

Further details of the presentations and the questions put to the discussion groups can be found at the following site:

www.who.int/nutrition/events/2016_bfhi_congress_24to26oct/en/indix1.html

The Baby-Friendly Hospital Initiative Congress was held October 24-26,  2016 at the World Health Organization Headquarters in Geneva, Switzerland.

Dr Rukhsana Haider, MBBS, MSc, IBCLC, PhD is Founder and Chair, Training & Assistance for Health & Nutrition (TAHN) Foundation, Chair, Civil Society Alliance for Scaling Up Nutrition, Bangladesh (CSA for SUN, BD), and Co-Chair, Steering Committee, World Alliance for Breastfeeding Action (WABA), Penang, Malaysia.

Felicity Savage is a paediatrician by training, who worked for a total of 18 years in Zambia, Indonesia and Kenya as a clinician in primary care, and was involved with the Baby Friendly Hospital Initiative from its inception. Felicity was an Honorary Senior Lecturer at the Institute of Child Health London, from 1979, where she founded the 4 (later 3) week Breastfeeding Practice and Policy (BFPP) course which continued  from 1992 to 2012.  In 1993 She joined the World Health Organisation in Geneva, specialising in the promotion of breastfeeding. With WHO, she co-ordinated the development of in-service courses on breastfeeding counselling and HIV and infant feeding.  She was part of the team that developed the Global Strategy on Infant and Young Child Feeding, and she edited a number of technical documents on different aspects of breastfeeding for WHO. Since retiring from WHO in 2001, Felicity has continued  to work as a freelance consultant, and Director of the Infant Feeding Consortium cic, based in Brighton UK, she particularly enjoys visiting countries where there are participants from BFPP courses, to help them to develop their plans for breastfeeding promotion and training.  She is now Chairperson of the Steering Committee of the World Alliance for Breastfeeding Action (WABA), which collaborates with the IFC to teach the 2-week course Breastfeeding Advocacy and Practice in Penang, Malaysia. She lives in Leeds in the north of England.

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