Hospitals and maternity units set a powerful example for new mothers. The Baby-Friendly Hospital Initiative ( BFHI ), launched in 1991, is an effort by UNICEF and the World Health Organization to ensure that all maternity services, whether free standing or in a hospital, become centers of breastfeeding support.
A maternity facility can be designated ‘baby-friendly’ when it does not accept free or low-cost breastmilk substitutes, feeding bottles or teats, and has implemented 10 specific steps to support successful breastfeeding including in the context of HIV and provides adequate support to mothers at birth.

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The process is currently controlled by national breastfeeding authorities, using Global Criteria that can be applied to maternity care in every country. Implementation guides for the BFHI have been developed by UNICEF and WHO.More…

BFHI New Documents, Part II provides the Global Criteria and outlines how to transform hospital practices. Part IV and Part VI help to verify the ending of free and low-cost supplies of breastmilk substitutes. Additional BFHI Parts, including questionnaires used by external teams to assess facilities before Baby-Friendly designation, may be requested when appropriate from the breastfeeding authority of each country.

Please see the following list of Baby Friendly Hospitals on a country by country basis. In areas where hospitals have achieved baby-friendly status, more mothers are breastfeeding their infants, and child health improves as a consequence.

Since the BFHI began, more than 15,000 facilities in 134 countries have been awarded Baby-Friendly status. In many areas where hospitals have been designated Baby-Friendly, more mothers are breastfeeding their infants, and child health has improved. News of the BFHI accomplishments and articles about effective breastfeeding programmes have been published for ten years in UNICEF BFHI News.

New knowledge about breastfeeding and its management has been provided through publication of training courses, and through recommendation of selected Breastfeeding Papers of the Month.

TEN STEPS TO SUCCESSFUL BREASTFEEDING
A REVISED VERSION BASED ON THE NEW UNICEF/WHO TRAINING MODULES 2006

Step One: Have a written breastfeeding policy that is routinely communicated to all health care staff.
· Most women are not infected and health workers shall continue to protect, support and promote breastfeeding in health facilities.

· Voluntary counseling and testing must be available before women can make their decision regarding infant feeding;

· The use of feeding bottles is prohibited, since bottle feeding seriously interferes with the suckle/lactation reflex and increases the risk of infection.

· Cup feeding should be promoted for those using artificial feeding or expressed breastmilk.

· Publicity by manufactures of breastmilk substitutes and baby foods should be prohibited within Health Facilities and to general public.

· Free and low cost supplies of breastmilk substitutes from manufacturers and distributors, free samples, even if some mothers are giving replacement feeds are prohibited. The little artificial feeds needed shall be purchased using normal national procurement methods.

Step Two: Train all health care staff skills necessary to implement this policy

The staff shall be trained on:

a) Breastfeeding and all infant and young child feeding issues, including lactation management, BFHI, feeding in difficult circumstances, support for mothers after delivery and empowering working mothers to succeed in optimal care and feeding of their infants.

b) Breastfeeding counseling to support all women who are negative, those who do not know their status and those who choose to breastfeed, even when HIV positive.

c) How HIV is transmitted and importance of VCCT

d) The need to help HIV positive mothers in assessment of risks of not breastfeeding, and support the decision of mothers of their feeding choices.

e) How mothers and other caregivers who need artificial feeding can use it safely.

f) How to avoid spill-over of artificial feeding by keeping feeds and equipment out of sight of other mothers and conducting demonstration on replacement feeding in private.

Step Three: Inform all pregnant women about the benefits and management of Breastfeeding

Mothers shall be informed about:

§ The benefits and management of breastfeeding,

§ How to avoid and treat breast conditions when breastfeeding.

§ How to succeed with exclusive breastfeeding for 6 months.

§ How to express breastmilk for sick or low birth weight babies.

§ Prevention of HIV/AIDS.

§ HIV and mother-to-child transmission.

§ The importance of confidential counseling and testing.

§ The dangers of artificial feeding and the importance of having adequate supply to substitute to last at least 12 months.

§ The importance of family planning.

Step Four: Help mothers to initiate breastfeeding within a half-hour of birth

§ All breastfeeding mothers should be helped to hold their babies skin-to-skin immediately after delivery; should be assisted to breastfeed within half an hour of delivery; and should be helped to position and attach the baby on the breast.

§ A mother who has chosen not to breastfeed after adequate counseling, because of HIV or any acceptable medical reason, needs encouragement to hold, cuddle and have early skin-to-skin contact with her baby.

§ The HIV positive mother, who after adequate counseling has decided to breastfeed, should be assisted to put the baby to the breast soon after delivery in the usual way and needs extra help with positioning and attachment to prevent breast conditions, such as breast engorgement, sore and cracked nipples, and breast abscesses.

§ The HIV positive mother who after adequate counseling, decides not to breastfeed should be helped to prepare and safely initiate replacement feeding of her choice and receive adequate follow up support.

Step Five: Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants

All breastfeeding mothers shall be shown how to:

§ Establish breastfeeding,

§ Use a good technique in positioning and attachment to prevent nipple damage and mastitis,

§ Breastfeed exclusively for six months,

§ Express breast milk by hand,

§ Breastfeed on demand

§ Non breastfeeding mothers need to be shown how to prepare and keep safely the replacement substitute.

Health workers should be aware that:
§ Mothers who choose not to breastfeed after they have been well counseled and guided need to discuss what alternative milk they will use. They should then be shown how to prepare it and give it to the baby and how to keep it safely. Instructions should be given privately and confidentially to avoid stigmatizing the mother and to avoid adverse influences on breastfeeding mothers.

§ Mothers who have decided not to breastfeed may need help with breast care while waiting for milk production to cease.

Step Six: Give newborn infants no food or drink other than breastmilk, unless medically indicated

All mothers should be taught about the benefits of breastfeeding to all children. They should be taught about the risks of artificial feeding and the extra care needed if the baby is not breastfeeding.

If a mother has been counseled on HIV, tested and found to be HIV positive, she should then be counseled on infant feeding options and about the benefits and risks of each option. If after adequate counseling she then decides not to breastfeed, this is an acceptable medical reason for giving her newborn infant other milk in place of breastmilk.

Even if many mothers are giving replacement feeds, this does not prevent a hospital from being designated as Baby and Mother Friendly, if those mothers have all been adequately counseled, offered testing, helped to consider all the risks and benefits of not breastfeeding, and made a genuine choice.

If a mother chooses to breastfeed she will need help to do so exclusively for six months and avoid the potentially more dangerous mixed feeding.

Step Seven: Practice rooming-in, allow mothers and infants to remain together 24 hours a day

All babies benefit from being near their mother, rooming-in or bedding-in, as this promotes bonding and encourages demand feeding.

Mothers who for some medical reason are not breastfeeding do not need to be separated from their babies as they also need to bond and demand feed on the replacement feed of choice.

Babies who are meant to feed on replacement feeding from birth need sometime before feeding on the replacement feed. They should not be given artificial feed in the first hour because their digestive systems are still too delicate.

Step Eight: Encourage breastfeeding on demand
BREASTFEEDING ON DEMAND HELPS ESTABLISH A GOOD MILK SUPPLY

§ For breastfed infants encourage breastfeeding on demand.

§ For artificially fed infants, encourage the mother to prepare a feed as often as the baby needs a few hours after delivery.

Step Nine: Give infants no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants

Teats, bottles and pacifiers can carry infection and are not needed, even for non-breastfeeding infant.

Cup feeding is recommended for non-breastfeeding infants.

Step Ten: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospital or clinic.

Health workers shall help to strengthen existing community support systems and where they have weakened, encourage establishment of Mother Support Groups.

Mothers who are not breastfeeding, in a community where most mothers breastfeed, may need extra support from a special mother support groups.

HIV and Infant Feeding

Health workers shall be trained on:

§ HIV/infant feeding, VCT, PMTCT, feeding choices, prevention of HIV, how to minimize spill over, dangers of mixed feeding

§ Confidentiality and privacy as relates to HIV in pregnant women.

§ Procedures for preventing HIV during delivery and after delivery.

§ How to minimize transmission if an HIV positive mother breastfeeds.

Health care staff shall counsel mothers on:

§ HIV/AIDS, family planning, pregnancy and infant feeding.

§ PMTCT

§ Importance of VCT for pregnant women

§ How to make informed decisions about feeding infants when HIV positive.

There should be:

· A written instruction about benefit and risks of each replacement feeding

· A written instruction about how to prepare replacement feeds

· A written instruction about how to express mother milk by hand

Compliance to the International Code of Marketing of Breatmilk Substitutes and Relevant Resolutions
The health facility shall have a breastfeeding policy that upholds the Code of Marketing, relevant resolutions of the World health Assembly and national Laws on the same, and shall:

§ Ensure that all infant feeding products for feeding of infants and young children must be purchased by the facility following tendering procedures.

§ Prohibit free or low cost supplies (less than 80% of retail price) in any health facility

§ Prohibit the display of posters or other promotional materials provided by manufacturers or distributors of breastmilk substitutes, bottles, teats, dummies or any other material that may promote their use

§ Prohibit direct contact with employees of distributors or manufacturers of companies dealing with infant and young child feeding products, in health facilities

§ Prohibit the facility from receiving free gifts, literature, materials, equipment, money or support for in-service training or conferences from manufacturers or distributors of products within the scope of the Code, relevant resolutions and national Laws.

§ Prohibit manufacturers and distributors from giving pregnant mothers, lactating mothers, or their close family members, marketing materials or samples, or gift packs of any product within the Scope of the Code, relevant resolutions or national laws.

The staff shall be trained

· About the importance of the International Code, national Law and relevant WHA resolutions.

· On reasons why it is prohibited to receive gifts, promotional materials, money, and any other incentives for health workers from manufacturers and distributors of products within the scope of the Code.

There shall be no promotional materials, displays, posters, written handouts, breastmilk substitutes, bottles, teats, pacifiers, dummies, or any other designated product within the scope of the national Law or the International Code and relevant resolutions, in any part of the health facility.

Infant formula cans or prepared bottles shall be kept out of view of other mothers in the wards to avoid spill over effect.

Mother Friendly Care
Written hospital policies require mother/baby friendly labour practices, including

* Encouraging women to have companions of their choice for emotional support throughout labour and birth,
* Allowing women to drink and eat light foods during labour if desired,
* Allowing women to walk or move about during labour where possible and assume positions of their choice during birth if there is no complications,
* Care that reduce use of invasive procedures such as rupture of the membrane, episiotomies, induction of labour instrumental deliveries and caesarean sections, unless necessary.

IBFAN Africa Regional office Technical Working Group,

1. Conducts advocacy with governments so that they continue implementing the initiative at all levels,
2. Supports national training and facility assessments for baby friendly status,
3. Provides relevant information to groups to update them on new knowledge, and
4. Monitors regional progress