Updating evidence for the WHO Baby Friendly Hospital Initiative Mother and Infant Research Unit Updating evidence for the WHO Baby Friendly Hospital Initiative Alison McFadden, Senior Research Fellow, Director, Mother and Infant Research Unit, University of Dundee

http://nursingmidwifery.dundee.ac.uk/mother-and-infant-research-unit

Baby Friendly Hospital Initiative 1989: Ten steps to successful breastfeeding 1991: Baby Friendly Hospital Initiative launched by WHO and UNICEF 2009: BFHI guidance last updated 2017: Updated guidance published

New WHO/UNICEF guidance Scope Maternity facilities only Includes preterm and low birthweight newborns Two aspects Guidelines on patient care (Ten Steps) Implementation guidance for national programmes (BFHI)

Guidance on patient care Key inputs 21 literature reviews on Ten Steps Systematic reviews of women’s values and preferences Systematic review of providers’ perspectives

http://www. cochranelibrary http://www.cochranelibrary.com/app/content/special-collections/article/?doi=10.1002/14651858.10100214651858

Enabling breastfeeding for women and babies Support for breastfeeding women Support for healthy breastfeeding mothers with healthy term babies Health promotion and enabling environment Interventions for promoting the initiation of breastfeeding Education and training of healthcare staff Care for breastfeeding women and their babies Treatment of breastfeeding problems Feeding practices for preterm babies/babies with additional needs and their mothers

http://onlinelibrary. wiley. com/doi/10. 1002/14651858. CD001688 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001688.pub3/full

Background near universal initiation rates High Income Countries Low and Middle Income Countries near universal initiation rates low rates of initiation within first hour after birth World average 44% India 23.3% Pakistan 18.4% low initiation rates overall particularly among women in lower income groups Norway 95% UK 81% US 79% France 63%, ROI 55%

Background Interventions Health education, peer support, practical skills training and early mother and baby contact Address structural, societal, health system, individual and economic influences to the decision to breastfeed Can be targeted at women, families, wider communities/society or healthcare staff

Objectives Effectiveness of breastfeeding promotion activities on number of women who initiate breastfeeding. number of women who initiate breastfeeding within one hour after birth

Methods Search conducted 29 Feb 2016 Study eligibility Randomised controlled trials any breastfeeding promotion intervention any population group except women and infants with a specific health problem.

Results: study settings 4 20 1 1 1 28 included trials of 107,362 women in seven countries 24 initiation (USA, UK, Nicaragua) 3 early initiation (Malawi, Nigeria, Ghana) 1 28 trials 107362 women 7 countries

Breastfeeding Education Delivered by healthcare professionals improved breastfeeding initiation RR 1.43, 95% CI 1.07 to 1.93 (5 trials, 564 women) Delivered by non-healthcare professionals (support/counselling by peer supporters, doulas, lactation educators, trained credit officers, community health workers) 1. Improved initiation RR 1.22, 95% CI 1.06 to 1.40 (8 trials, 5712 women) 2. Positive non–significant effect on early initiation RR 1.70, 95% CI 0.98 to 2.95 (2 trials, 76373 women)

Other interventions No evidence of improved initiation Breastfeeding education delivered by healthcare professionals with peer support (1 trial of 390 adolescent women) Breastfeeding education delivered by multi-media (self-help manual, video) (2 trials of 497 women) Early mother-infant contact (2 trials of 309 women) Community-based support groups (1 trial, 18603 women)

Conclusions Low-quality evidence healthcare professional-led breastfeeding education and/or non- healthcare professional-led counselling and/or peer support can improve breastfeeding initiation majority of trials were conducted in the USA, among women on low incomes and who varied in ethnicity and feeding intention - limits the generalisability of results to other settings

http://onlinelibrary. wiley. com/doi/10. 1002/14651858. CD001141 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001141.pub5/full

Background High Income Countries Low and middle income countries In some countries - marked decline in breastfeeding after first few weeks Low rates of exclusivity up to 6 months and continuation beyond 12 months Generally higher rates of breastfeeding duration than in HICS Variable rates of exclusive breastfeeding for 6 months World average 37%

Background Interventions Support - complex intervention to address multi-faceted barriers to breastfeeding Information/education – e.g. to dispel myths Skills to manage breastfeeding – positioning and attachment, solving problems Confidence and esteem-building Practical support – help with other tasks Social support – creating supportive networks

Objectives To assess the effectiveness of support for breastfeeding of healthy mothers with healthy babies Timing and setting of interventions Different modes of support – proactive/reactive; face-to-face/telephone; antenatal/postnatal; Different care providers Interaction between support interventions and background initiation rates

Methods Search conducted 29 Feb 2016 Study eligibility Randomised controlled trials Comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care

Study settings and participant numbers

Effect of all types of support on any breastfeeding Cessation of any breastfeeding before 4-6 weeks Breastfeeding support reduces number of women stopping breastfeeding before 4-6 weeks (33 trials with 10,776 women) RR 0.86, 95% CI 0.79 to 0.93 (31.4% vs 35.3%) Cessation of any breastfeeding up to 6 months Breastfeeding support reduces number of women stopping breastfeeding before 6 months (40 trials with 14,227 women) RR 0.89, CI 0.85 to 0.93 (50.5% vs 57.3%)

Effect of all types of support on exclusive breastfeeding Cessation of exclusive breastfeeding before 4-6 weeks Breastfeeding support reduces number of women stopping exclusive breastfeeding before 4-6 weeks (32 studies with 10,271 women) RR 0.79, 95% CI 0.69 to 0.89 (55.4% vs 64.2%) Cessation of exclusive breastfeeding up to 6 months Breastfeeding support reduces number of women stopping exclusive breastfeeding before 6 months (46 studies with 18,303) RR 0.89, 95% CI 0.86 to 0.93 (74.9% vs 82.3%)

Sub-group analyses Lay support may be more effective than professional or mixed support (exclusive breastfeeding before 6 months) Face-to-face support may be more effective than other types of support Antenatal component vs postnatal only made no difference Greater effect on exclusive breastfeeding in settings with breastfeeding initiation >90%

Conclusions All women should be offered breastfeeding support. Support that is provided either only in the postnatal period or in both the antenatal and postnatal period is effective. Support may be offered either by professional or lay/peer supporters, or a combination of both. Support for exclusive breastfeeding is likely to be more effective in settings with high initiation rates, so efforts to increase the uptake of breastfeeding should be in place. Strategies that rely mainly on face-to-face support may be more likely to succeed for women practising exclusive breastfeeding.

https://internationalbreastfeedingjournal. biomedcentral https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/s13006-016-0097-2

Background Healthcare staff need Knowledge – health outcomes, physiological processes Attitudes – positive, non-judgemental Skills – communication, information provision, practical skills Evidence that many staff don’t have these Lack of evidence of what works to equip staff with above e.g. no RCTs Previous SR have examined effect of staff training on breastfeeding rates but not on knowledge, attitudes or skills

Objective To determine whether: Secondary outcomes- BFHI, the Code education and training programmes for supporting breastfeeding women (intervention) have an effect on knowledge and attitudes (primary outcomes) of healthcare staff (population) compared to not training/usual training (comparator) Secondary outcomes- BFHI, the Code

Results 4 trials (6 papers) of 263 participants Participants: midwives and postnatal nurses (1), health visitors (1), paediatricians, obstetricians and nurses (1), not clear (1) Settings: Brazil (2), Denmark (1), Sweden (1) Interventions: WHO 18-hour course (1), WHO 40-hour course (1), WellstartTM Lactation programme (1), developed process orientated programme (1) Outcomes: knowledge (3), attitudes (2) – measured at different times, different instruments (none validated), follow-up in intervention group only (2)

Results Unable to do meta-analysis, All studies high or unclear risk of bias 1. Breastfeeding knowledge: 2 studies (Kronborg 2008; Rea 1999) Small but significant positive effects in the healthcare staff receiving the intervention 2. Breastfeeding attitudes: 2 studies (Ekstrom 2005; Kronborg 2008) Inconsistent findings – small but significant effect of some measures

Results Secondary outcomes 1. Compliance with BFHI – 1 study (Rea 1999) Health visitors who received the 18 hour WHO course were significantly more likely to perform a demonstration of how to breastfeed to mothers 2. Adherence to the Code - no studies

Conclusions Lack of good quality evidence on whether breastfeeding training and education for healthcare staff can help improve breastfeeding knowledge and attitudes Small but significant positive effects for measures of knowledge, some measures of attitudes, and performance of BFHI step five Evidence extremely limited (few trials, poor quality) Has implications for effectiveness of breastfeeding support interventions

Summary 1. Breastfeeding support extends the length of any and exclusive breastfeeding 2. Professional-led breastfeeding education and lay counselling and peer support can promote initiation of breastfeeding 3. Lack of evidence on whether breastfeeding training and education for healthcare staff improves breastfeeding knowledge and attitudes

@AlisonMcFDundee @MIRU_UK Mother-to-mother support groups in the community, accompanied by communication strategies to promote breastfeeding, using multiple channels and messages tailored to the local context a.m.mcfadden@dundee.ac.uk @AlisonMcFDundee @MIRU_UK