The Baby-friendly Hospital Initiative (BFHI) was launched by UNICEF and WHO in 1991. It is a world-wide endeavour to improve maternity care practices that were that are associated with successful establishment of early and exclusive breastfeeding. The practices were codified as the Ten Steps, developed in the 1980s, which include Protection (Steps 6 and 9) from distructive practices, Promotion (Steps 1 and 3) of optimal feeding, and Support (Steps 2, 4, 5, 8, 9 and 10) for practices and conditions that are associated with optimal infant feeding.
The process started in the 1980’s with the WHO/UNICEF Joint Statement: Protecting, promoting and supporting breastfeeding: The special role of maternity services, which drew attention to the critical role of health services for promoting breastfeeding, and in which the
"Ten Steps to Successful Breastfeeding" were first published. In 1990, the Innocenti Declaration put forward as one of its main targets to "Ensure that all maternity facilities fully practise the Ten Steps to Successful Breastfeeding set out in the WHO/UNICEF statement on breastfeeding and maternity services." The BFHI is called by various names around the world, including
"Baby-friendly Initiative" or BFI in the UK, which provides a very helpful website, or the Mother-Baby-friendly Initiative in some countries.
Since 1991, the BFHI has spread all over the world, with more than 152 countries and over 20,000 hospitals having been accredited as "baby-friendly", being awarded an official plaque, often with the well-known Picasso drawing of a breastfeeding mother, seen here. Tools and materials were developed for training of staff and assessment of practices to facilitate the implementation. Hospitals are accredited initially for a certain period of time, usually about 3-5 years, after which they must be reassessed and reaccredited, to ensure quality is maintained. Research on the impact of the initiative has shown it to be effective, and to increase breastfeeding rates. (See Tab below)
In 2009, revised tools and materials were produced by WHO and UNICEF to incorporate new evidence, and to expand the baby-friendly initiative to other healthcare settings and into the community in the context of the Global Strategy for Infant and Young Child Feeding. The updated materials reinforce implementation of the International Code of Marketing of Breast-milk Substitutes, introduce the concept of mother-friendly care, and care of pregnant women and mothers in the context of HIV and of emergencies. They include support for mothers who are not breastfeeding, and they provide more guidance for monitoring and reassessment.
Implementation may be initiated at national level, at regional level, or in individual hospitals, but either way includes the formation of a committee of relevant stakeholders to lead and guide the process. The persons responsible develop a plan of action, including a policy, and the training of all concerned staff, with outside help if necessary. A facility which aspires to become baby-friendly needs to conduct a self-assessment early in the process, to find out what practices need to change. Regular audits of practices are recommended to monitor developments.
The revised BFHI package includes:
Section 1: Background and Implementation, which provides guidance on the revised processes and expansion options at the country, health facility, and community level, recognizing that the Initiative has expanded and must be mainstreamed to some extent for sustainability, and includes:
1.1 Country Level Implementation
1.2 Hospital Level Implementation
1.3 The Global Criteria for BFHI
1.4 Compliance with the International Code of Marketing of Breast-milk Substitutes
1.5 Baby-friendly Expansion and Integration Options
1.6 Resources, references and websites
Section 2: Strengthening and sustaining the Baby-friendly Hospital Initiative: A course for decision-makers was adapted from the WHO course "Promoting breast-feeding in health facilities: A short course for administrators and policy-makers". This can be used to orient hospital decisions makers (directors, administrators, key managers, etc.) and policy-makers to the Initiative and the positive impacts it can have and to gain their commitment to promoting and sustaining "Baby friendly". There is a Course Guide and eight Session Plans with handouts and PowerPoint slides. Two alternative session plans and materials for use in settings with high HIV prevalence have been included.
Section 3: Breastfeeding Promotion and Support in a Baby-friendly Hospital, a 20-hour course for maternity staff, which can be used by facilities to strengthen the knowledge and skills of their staff towards successful implementation of the Ten Steps to Successful Breastfeeding. This section includes:
3.1 Guidelines for Course Facilitators including a Course Planning Checklist
3.2 Outlines of Course Sessions
3.3 PowerPoint slides for the Course
Section 4: Hospital Self-Appraisal and Monitoring, which provides tools that can be used by managers and staff initially, to help determine whether their facilities are ready to apply for external assessment, and, once their facilities are designated Baby-friendly, to monitor continued adherence to the Ten Steps. This section includes:
4.1 Hospital Self-Appraisal Tool
4.2 Guidelines and Tools for Monitoring
Section 5: External Assessment and Reassessment, which provides guidelines and tools for external assessors to use both initially, to assess whether hospitals meet the Global Criteria and thus fully comply with the Ten Steps, and then to reassess, on a regular basis, whether they continue to maintain the required standards. This section includes:
5.1 Guide for Assessors, including PowerPoint slides for assessor training
5.2 Hospital External Assessment Tool
5.3 Guidelines and Tool for External Reassessment
5.4 The BFHI Assessment Computer Tool
