SCALING UP BREASTFEEDING ACTIVITIES IN BRAZIL Marina F. Rea IBFAN National Committee of Breastfeeding, MoH Brazil WBC 2, December 2016

BREASTFEEDING OUTCOMES. Trends in Exclusive Breastfeeding 0-6 months in Brazil

BREASTFEEDING OUTCOMES. Trends in Median duration of breastfeeding in Brazil, in months

Exclusive Breastfeeding 0-6 months and BF trends comparing Brazil and Mexico, observing below the program coordination and gear model of execution in these countries Perez-Escamilla et al. Adv. Nutr. 3: 2012. These two countries may provide us interesting considerations on how to carry out a BF Prog, observing the trends in EBF 0-6 months, and also BF median duration. For many years Bra has had a national BF coordinator, has settle goeals The breastfeeding gear model for scaling up and sustainability of breastfeeding programs.

Minist.Health BF Coordination and assessors Committee BRAZILIAN BREASTFEEDING INCENTIVE PROGRAMME PRIMARY HEALTH CARE NETWORK HUMAN MILK BANK BFHI CODE Minist.Health BF Coordination and assessors Committee KANGAROO CARE WBW, CAMPAIGNS WORKING WOMEN & BF EDUCATION /INF 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. 

In January 2016 Brazil was a special mention at Lancet on Breastfeeding: “In Brazil, the length of breastfeeding increased dramatically from 2.5 months in 1974-75 to 14 months in 2006-07 due to a combination of policy, health service, civil society, and mass media initiatives.” According to Lancet “an increase in 10 percentage points on EBF 0-6 months and continuation till 2 years or beyond could represent a saving in 6 million US dollars in treatments in Brazil.” “A study in Brazil including 30 years of follow-up suggested an effect of breastfeeding on intelligence, attained schooling, and adult earnings, with 72% of the effect of bf on income explained by the increase in IQ”.

PRIMARY HEALTH CARE BREASTFEEDING & COMPLEMENTARY FEEDING NETWORK Recent years of improvement in this component: 3.992 tutours on BF & CF 210 workshops; Skilled capacity of 23.226 health workers at primary health care units; local training at1.753 UBS; 53 UBS certified by MoH, and more 108 UBAAM only in Rio de Janeiro.

PRIMARY HEALTH CARE BREASTFEEDING & COMPLEMENTARY FEEDING NETWORK 362 municipalities (6.5% ) with local trained health workers and health units. …still a lot to be done!

WORKING WOMEN AND BREASTFEEDING -Increase of maternity leave to 180 days to all working women Creche at workplace A room for express and storage breastmilk at workplace Workshops to form Tutors in each state Number of Tutors Number of companies with Room Number of certified Room for express & storage bm 29 671 231 175

WORKING WOMEN AND BREASTFEEDING MATERNITY LEAVE INCREASES EXCLUSIVE BREASTFEEDING in BRAZIL - a study with 15200 mothers. EBF: NO YES Do not work/ Work outside home/ work but in maternity leave

CHALLENGE: Different ways to work, different employers: how pregnant and lactating women can cope?

KANGAROO METHOD CARE A method to incentive mother and father to increase bonding with premature and low birth weight babies Brazil Maternities with KMC - 8,0% Profesionals skilled on the KMC: 25%

BABY-FRIENDLY HOSPITAL INITIATIVE Launched in 1991 in Brazil. In 1993 the first Hospital – IMIP, Recife, PE. In 1994 the first private hospital – became BFH Brazil BFHI criteria: To implement the Ten Steps to Successful Breastfeeding To implement the WHO Code of Marketing of Breast Milk Substitutes and national Code To implement the mother-friendly care for labour and delivery To allow parents to access the neonate at risk.

Training courses performed for the implementation of BFHI in Brazil 1992 - 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.

BABY-FRIENDLY HOSPITAL INITIATIVE Annual numbers of newly BFHI accredited hospitals in Brazil 382 hospitals were accredited for the BFHI, an average of 15 per year.

BRAZIL BABY-FRIENDLY HOSPITALS ACCORDING TO STATES AND TO THE PROPORTION OF NEONATES BORN IN BFHI 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 (2014) – 4705.

220 Banks 171 Human milk collect units HUMAN MILK BANK 9 13 10 57 14 18 7 5 3 1 4 6 15 Distribution of HMB according to states 220 Banks 171 Human milk collect units

SOCIAL MOBILIZATION AND CAMPAIGNS WORLD BREASTFEEDING WEEK AND DAY OF MOTHER´S MILK DONATION

BRAZILIAN CODE It is based in the International Code 1981 and subsequent relevant World Health Assembly Resolutions Approved in1988 – as a sanitary resolution Revised in1992 and in 2001. Approved as Law by parliament and signed by presidt. in 2006. Law regulated as a Decree 8552 in 2015. STRENGTHS: OBJECTIVE – includes protection of breastfeeding till 2 years and beyond SCOPE – includes infant formula plus baby foods and milks for young children till 3 years, bottles, teats, pacifiers, HMF, formulas for dietetic use. LABELS with WARNING – according to the type of product. COMMERCIAL PROMOTION - with WARNING – according to the type of product MONITORING – annually by strong IBFAN group present all over the country.

As a CONCLUSION, and according to The Lancet: “Brazil exemplifies a country with strong civil society engagement and participation, in which policies and programmes addressing all three levels of the conceptual framework (individual, settings, and structural) have been implemented simultaneously. The Code, enacted shortly after adoption by the World Health Assembly, has been updated three times and is rigorously monitored for compliance. Paid leave is available to mothers (24 weeks) and fathers (3 days). A systematic process for certification and recertification of hospitals as “Baby Friendly” to maintain quality standards has been instituted and health-worker training has been extensive. An innovative network of human-milk banks in more than 200 hospitals has established the use of human milk and breastfeeding as a valued and normative practice. Visible government leadership and investment and active civil society participation underpin Brazil’s breastfeeding achievements. (…) Nonetheless, it is the tenth largest market for baby milk formula, and is projected to reach $951 million by 2019.” Therefore, Breastfeeding implementation activities should continue strongly and always be a priority !

Thank you! …to have more breastfed healthy and wonderful children! marifrea@usp.br