Advances and Challenges of BFHI in Brazil: How to maintain quality Marina F. Rea IBFAN National Committee of Breastfeeding, MoH Brazil WBC2, December 2016

The Baby-friendly Hospital Initiative (BFHI) launched in 1991 was initiated in 1992 in Brazil. BFHI objectives: To implement the Ten Steps to Successful Breastfeeding To implement the 1981 WHO Code of Marketing of Breast Milk Substitutes

Minist.Health Coordination and assessors Committee BRAZILIAN BREASTFEEDING INCENTIVE PROGRAMME HUMAN MILK BANK PRIMARY CARE NETWORK BFHI CODE Minist.Health Coordination and assessors Committee Kangaroo Care WBW, CAMPAIGNS WORKING WOMEN AND BF EDUCATION/INFORMATION MATERIALS MONITORING Analogous to a well-oiled engine, our successful programme indicates the need for several key "gears" to be working in synchrony and coordination. 

Key child health indicators in Brazil (2015) Population …………………………….…….208 million PIB per capita.................................US$11.208 Under 5 mortality rate (/1000 live births)..16.4 Infant mortality rate (/1000 live births)……14.6 Key breastfeeding indicators – trends Early initiation of Breastfeeding……………………………………. 43% (2006) Exclusive breastfeeding in 0-5 months olds …3% (1986)…41% (2008) Median duration of breastfeeding…5 mo (1975)………….14 mo(2006)

BRAZIL TRENDS IN INDICATOR BF 24 months ONDE ESTAMOS: BRASIL BRAZIL TRENDS IN INDICATOR BF 24 months THE OTHER IMPORTANT BF INDICATORS – EBF -6mo, BF 12mo – DO NOT SHOW INCREASE IN 2013.

Annual numbers of newly BFHI accredited hospitals in Brazil between 1992 and 2016 382 hospitals were accredited for the BFHI, an average of 15 per year.

Training courses performed for the implementation of BFHI in Brazil between 1992 and 2015, sponsored and carried out by MoH. Courses Number of trained health professionals  Clinical management and Promotion of Breastfeeding 10.842 BFHI Training Course for Assessors 427 Breastfeeding Counseling Course 463 BFHI Short Course for Decision-makers 2.536 BFHI Updating Course for Assessors 234 Here is not included local training courses in municipalities and maternity hospitals, difficult to quantify.

BRAZIL NUMBER OF BABY-FRIENDLY HOSPITALS ACCORDING TO STATES AND PROPORTION OF NEONATES BORN IN BABY-FRIENDLY HOSPITALS 01 01 08 26 11 19 29 15 13 01 11 07 02 03 01 08 02 11 20 23 02 BABIES BORN IN BFH IN BRAZIL 03 15 40 year 2013 2014 Total births 2.904.030 2.979.133 % births in BFH 23% 27% 21 17 16 Total 326 BFH YEAR:2016 Number of maternity hospitals – 4705.

Brazilian criteria of BFHI 1994 1996 2001 2004 2011 2014

Annual numbers of newly BFHI accredited hospitals in Brazil between 1992 and 2016 382 hospitals were accredited for the BFHI, an average of 15 per year.

HOW BFHI IS FUNDED IN BRAZIL Since 1994, BFHI accredited hospitals receive financial incentives including higher reimbursements for best practices during delivery and birth. Currently this is 8.5 % more per caesarean section and 17% more per normal delivery. . Estimated cost for a global assessment ………US $750 p/hosp Since its inception BFHI has been funded by the government of Brazil (federal , states and municipality budgets). BFHI plaques are funded by the UNICEF Brazil office.

BFHI GOOD RESULTS: A recent national survey during the immunization campaign found that being born in a BFH was associated with timely breastfeeding initiation and longer EBF duration: 9% higher chance to be breastfed in the first hour of life. Median duration of 60 days of exclusive breastfeeding compared to 48 days when born in a non-BFHI hospital. Venancio S.I., Saldiva S.R., Escuder M.M. & Giugliani E.R. (2012) The Baby-Friendly Hospital Initiative shows positive effects on breastfeeding indicators in Brazil. Journal of Epidemiology & Community Health 66 (10), 914–8.

THE WAY FORWARD... BFHI process was revised in 2014 looking for better quality and sustainability From 2014 the accreditation process in the BFHI was revised including: Ten steps The Code Women´s friendly care during labour and delivery Access of parents to at risk babies in Neonatal Care Unit Hospital self monitoring annually using a computerized tool Reassessment each 3 years with external BFHI assessors, expire date. Update and training of old and new BFHI assessors in the new process Improving practices in private hospitals to accomplish the needed decline in C-sections in the country.

Thank you!