by Anne Eglash MD, IBCLC, FABM
What are the 2018 revisions to the Baby Friendly Hospital Initiative? The Baby Friendly Hospital Initiative was established by the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) in 1991, after recognizing that breastfeeding support immediately after birth is crucial to breastfeeding success and to lowering high infant mortality rates in many countries as the result of insufficient breastfeeding. The Baby Friendly Hospital Initiative involves the implementation of a standard of care for mothers and infants in hospitals/birthing centers, to optimize breastfeeding success right after birth. There is good evidence that implementing the Baby Friendly Hospital Initiative leads to increased breastfeeding rates at the time of hospital discharge.
The 10 steps of the Baby Friendly Hospital Initiative have been revised recently, based on challenges faced by countries and institutions in the implementation and sustainment of the changes in birthing centers. Some of these challenges include limited resources for training staff, the pressure to continue accepting free formula, and the lack of outpatient breastfeeding support for dyads leaving the birthing center.
What do you think are changes to the BFHI 10 steps? Choose 1 or more:
- Step 1 is changed from ‘Have a written breastfeeding policy that is routinely communicated to all health care staff’. It adds i) comply fully with the International Code of Marketing of Breastmilk Substitutes, and ii) establish ongoing monitoring and data-management systems
- Step 3 is changed from ‘Inform all pregnant women about the benefits and management of breastfeeding’ to ‘Discuss the importance and management of breastfeeding with pregnant women and their families’
- Step 4 is changed from ‘Help mothers initiate breastfeeding within one hour of birth’ to ‘Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.’
- Step 9 is changed from ‘Give no pacifiers or artificial nipples to breastfeeding infants’ to ‘Counsel mothers on the use and risks of feeding bottles, teats and pacifiers’
- Step 10 is changed from ‘Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center’ to ‘Coordinate discharge so that parents and their infants have timely access to ongoing support and care.’
See the Answer
All of the Above
The Ten Steps to Successful Breastfeeding Revised 2018
Critical management procedures
- 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.
- c. Establish ongoing monitoring and data-management systems.
- 2 Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding.
Key clinical practices
- 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 practice 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.
Milk Mob Comment by Anne Eglash MD, IBCLC, FABM
Several of the changes to the Ten Steps to Successful Breastfeeding as outlined by BFHI appear to be driven by experience and practicality. For example, it makes sense for Step 4 that we should not be timing the initial breastfeed to occur in the first hour. What is most important is the process by which infants ‘arrive to the dinner table’ so to speak, recognizing that immediate skin-to-skin after birth is just as valuable for the mother and infant as the ‘measurable goal’ of early breastfeeding.
The change in wording invites shared decision-making between mothers, family, and hospital staff. For example, Step 9 is changed from a command of not giving pacifiers or artificial nipples, to counseling mothers on the use and risks, allowing her to make that informed decision.
The changes for Step 10 appear rather substantial and are the most concerning to me. The content changed from ‘fostering the establishment of breastfeeding support groups and refer mothers to them…’ to ‘coordinate discharge so that parents and their families have timely access to ongoing support and care’. While I agree that breastfeeding support groups are awesome for addressing the psychosocial challenges of breastfeeding, they are unable to address individual breastfeeding medicine needs or medical complications that a dyad may have. For this reason, the change to coordinating outpatient support makes sense. However, in the USA, hospitals are increasingly investing in outpatient clinics for financial reasons, so they are prime candidates to foster and develop outpatient breastfeeding support strategies. We need to expect hospitals associated with outpatient medical systems to take responsibility in building strong sustainable systems for outpatient breastfeeding support and management. Until we amp up the knowledge, skills, and commitment for breastfeeding support in outpatient medical institutions, Baby Friendly will remain in its silo, training mothers to prepare for their breastfeeding marathons, yet sending the dyads into an outpatient desert with little sustenance and unacceptable risks of morbidity related to breastfeeding complications for both mother and infant. Just ask Fed Is Best.