In October of last year, WHO and UNICEF released proposed new guidelines for the Baby-Friendly Hospital Initiative (BFHI) in a document called Protection, Promotion, and Support of Breastfeeding in Facilities Providing Maternity and Newborn Services: The Revised Baby-friendly Hospital Initiative 2017.
WHO developed new guidelines for the Ten Steps based on systematic evidence reviews on each of the steps. The guidelines were written by an external Guideline Development Group following standard WHO procedures, according to WHO’s website.
WHO and UNICEF opened a comment period for public consultation on the document, but many expressed concern over the brevity of the comment period. In fact, in an email addressed to Friend(s) of Baby-Friendly USA, BFUSA Executive Director Trish MacEnroe wrote: “Baby-Friendly USA (BFUSA) first saw this document on October 11 and, like all other global BFHI and breastfeeding experts, we were given less than two weeks to fully digest its contents and consider its ramifications.” In her email, MacEnroe acknowledged the importance of the document for Baby-Friendly practices around the world.
MacEnroe also addressed concerns from currently designated facilities and those in the 4D Pathway.
“Stay the course,” she wrote. MacEnroe explained that the proposed changes are a long way from being implemented; a process that first requires WHO to synthesize feedback into official language and then for BFUSA to develop an implementation strategy.
“In the meantime, the current standards are in place and will remain in place for the foreseeable future,” she offered.
Challenges and criticism of BFHI
As Dr. Fiona Dykes, head of the the Maternal and Infant Nutrition and Nurture Unit (MAINN) at the University of Central Lancashire (UCLAN), explained in her presentations at the latest International Breastfeeding and MAINN Conference, the approach of the WHO/UNICEF sponsored BFHI has been met with criticism over the course of its 25 years in existence.
Its top-down, bureaucratic approach using protocols, policies and surveillance, can be challenging to implement and operationalize in a culturally sensitive way, Dykes said.
Further, this approach can lead to “ritual behavior” where care providers care for the institution before the mother, sometime breaking rules to satisfy a task, she went on. Still, participating systems sometimes have inadequate compliance with the Code.
BFHI relies on breastfeeding champions and when these individuals retire, the process falters.
“The rug is pulled from under the initiative when you take away the breastfeeding champion,” Dykes said.
The same idea applies to its reliance on external donors rather than government budgets; Take away the money, and again the rug is pulled out from under the initiative.
A focus on individual facilities’ accomplishments versus national standards challenges BFHI as an initiative too. The emphasis on awards and status is not a sustainable model, Dykes commented.
What’s more, BFHI unintentionally encourages an inequitable system where some mothers have access to Baby-Friendly designated facilities and gold standard care, and other mothers birth in communities where “it’s not even talked about,” Dykes said.
WHO estimated that as of 2017, only about 10 percent of babies in the world were born in a facility currently designated Baby-Friendly.
Revising BFHI
In an effort to address these shortcomings, WHO and UNICEF created updated directions for BFHI implementation.
The document, while criticized for being poorly written, offers a refreshing tone with guidance focused on close and loving relationships.
“Mothers should be supported to recognize and respond to their infants’ cues for feeding, closeness and comfort, and enabled to respond accordingly to these cues with a variety of options, during their stay at the facility providing maternity and newborn services…” one line reads.
It goes on, “Supporting mother to respond in a variety of ways to behavioural cues for feeding, comfort or closeness enables them to build a caring, nurturing relationship with their infants and increases their confidence in themselves, in breastfeeding and in their infants’ growth and development.”
The document also addresses items like establishing national standards, integrating into other health systems, and establishing regular internal monitoring and external assessment.
Dykes commented: “The bottom line is as long as we are getting best practice, then how that works doesn’t matter too much, as long as it can be embedded and sustained.”
For example, she referenced UK BFHI which, while still embracing the 10 Steps, is “doing their own thing.”
“They have a very nuanced approach,” Dykes said.
Research Associate at DECIPHer, Cardiff University and Research Manager for NCT Heather Trickey wrote Can we have better conversations about breastfeeding? in light of UNICEF’s Call to Action on Infant Feeding in the UK, a campaign centered around four key actions which includes implementing evidence-based initiatives that support breastfeeding like the Unicef UK Baby Friendly Initiative.
“We deeply admire the work of our colleagues in the UK,” MacEnroe wrote in an email to Our Milky Way. “When we see the final document from WHO, we will consider a variety of options for implementing the revisions. Our goal is to create the best and most effective breastfeeding support program for mothers and babies in the US.”
Stay tuned to learn more about UK BFHI and Trickey’s work next week on Our Milky Way.