BFHI Congress 2016 New Guidance on the Protection, Promotion, and Support of Breastfeeding in Maternity Facilities Laurence M. Grummer-Strawn, PhD WHO Department of Nutrition for Health and Development World Breastfeeding Conference Johannesburg, South Africa December 12, 2016

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

BFHI Congress 2016 Celebrate 25 years of achievements Take stock of where we are Chart a course for the future Build networks of support Sponsored by WHO & UNICEF October 24-26, 2016 Geneva, Switzerland 302 participants Representation from 133 countries

Celebrate 25 years of achievements

Celebrate 25 years of achievements Over 20000 facilities designated BFHI reflected in global health policy 1990 Innocenti Declaration, 2002 Global Strategy on Infant and Young Child Feeding, 2012 WHA nutrition target, 2014 ICN2 Framework for Action, 2015 Global Nutrition Monitoring Framework Clear impact on breastfeeding Escamilla-Perez (2016) reviewed 58 studies and demonstrated that adherence to the Ten Steps impacts breastfeeding rates

Take stock of where we are

Country experiences The case studies are from 15 countries and territories: Bolivia, Brazil, China, Ghana, Ireland, Kenya, Kuwait, Kyrgystan, New Zealand, Philippines, Saudi Arabia, South Africa, Taiwan, United States of America and Viet Nam. The case studies were submitted based on a combination of a general call for case studies among UNICEF and WHO offices, and specific targeting through networks. The KII were undertaken by the ERG members; each undertook

Coverage of BFHI by WHO region Coverage is defined as: % of births whenever we have it, and the regional averages are all weighted by the number of births in each country.  When data for % of births are missing, % of facilities used as a proxy.

Key challenges for both facilities and countries Voluntary nature Dependence on champions Funding Training Assessment Staff workload

Timing of BFHI designations and redesignations, PAHO Number of facilities

Build networks of support

Chart a course for the future

Why Updated Guidance is Needed? Challenges in implementation Scientific rigor of WHO guideline development Last update written in 2006-2007 Silver anniversary

Process for Development of Guidance Steering committee established in WHO and UNICEF in 2015 Scope Maternity facilities only Includes preterm and low birthweight newborns Two aspects Guidelines on patient care Implementation guidance for national programmes

Guidelines on patient care Process governed by WHO Guidelines Review Committee Guidelines Development Group (GDG) Key inputs: 21 systematic literature reviews on Ten Steps Systematic review of mothers’ values and preferences Systematic review of provider perspectives Meetings in April and November 2016

Implementation guidance for national programmes External Review Group (ERG) Key inputs: Case-studies Key informant interviews Global survey Review of key documents Meetings in December 2015, April 2016, October 2016

Process for Development of Guidance Implementation Guidance Review at BFHI Congress Patient Care Guidelines Draft Guidance Peer review Public comment Final Guidance

Discussion at Updated Guidance Four presentations on draft guidance Implementation in maternity facilities Setting national health care standards National implementation National leadership and coordination Following each presentation Q&A 9 working groups Feedback in plenary

Key principles driving changes Integrated people-centred health services Improving quality of care Strengthening health systems

Key points in the new guidance BFHI should be responsibility of every maternity facility Countries need to establish national standards of care Must include private facilities, not just public Must be integrated with other health care improvement and quality assurance initiatives Incentives other than designation are encouraged Regular internal monitoring is a crucial element External assessment needs to be streamlined enough to be manageable within existing resources

Key elements of national BFHI Incorporation of standards into national policy documents and professional standards of care Capacity building of health professionals and managers (pre- service and in-service) External assessment systems Incentives for compliance with the national standards Strategies to scale up to all maternity facilities Monitoring systems on the implementation of the programme Ongoing funding of the initiative Key elements of implementing BFHI nationwide   Oversee BFHI implementation in all maternity facilities in the country, including public as well as private facilities. Incorporate the protection, promotion and support of breastfeeding in maternity facilities into all relevant national policy documents and professional standards of care. Ensure that all health professionals and managers engaged in maternal and newborn care have adequate capacity to implement the national BFHI standards and management procedures. Develop external assessment systems to regularly evaluate the adherence of maternity facilities to the national BFHI standards. Develop and implement incentives for compliance and/or sanctions for non-compliance with the national standards. Execute strategies to scale up application of the BFHI standards to include all maternity facilities. Develop and maintain a monitoring system on the implementation of the programme. Ensure the ongoing funding of the initiative.

Key conclusions from feedback Breastfeeding should be treated as the norm in all countries BFHI should be mainstreamed as much as possible into other programmes, initiatives, policies Increased advocacy is needed BFHI should cover both healthy and preterm/LBW newborns BFHI should cover public and private facilities The Code should remain a strong part and parcel of the BFHI Guidance should recognize different country contexts There are challenges to operationalize all these issues

Process for Development of Guidance Implementation Guidance Review at BFHI Congress Patient Care Guidelines Draft Guidance Peer review Public comment Final Guidance

Thank you