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Baby-Friendly in 2018: Are Revisions Better or Worse?

The World Health Organization (WHO) and UNICEF recently issued their new document, Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: The revised Baby-Friendly Hospital Initiative (BFHI) 2018. Are the revisions better or worse than the original 1989 document? To answer that, I started by reading this 47-page implementation guide with 5 sections:

  • Introduction
  • The role of facilities providing maternity and newborn services
  • Country-level implementation and sustainability
  • Coordination of the Baby-friendly Hospital Initiative with other breastfeeding support initiatives outside facilities providing maternity and newborn services
  • Transition of BFHI implementation

These 5 sections are followed by 3 annexes, and references.

Done. But are revisions better or worse?

The WHO asked for public input in 2017. Now, the document is set in stone.

Over the past several days since its release, I’ve worked on wading through the new document. As a US-based nurse who has spent years working in hospitals, my opinion might not reflect the opinion of others in other countries or in other roles. (But that won’t stop me from forming an opinion on whether these revisions are better or worse!)

What are the questions?

If you’re like me, you’re wondering how these new recommendations will affect professionals, and parents. What will be the expectations of professionals? Will these revisions result in care that is better or worse for parents? What impact will the recommendations have — if any — on care at the societal level?

I have an even bigger question. Why did WHO feel it was time to write a revised document, and create this new implementation guide? Introductory remarks state that the BFHI movement often has not been initiated or sustained since its 1991 launch. That seems to dimly imply the impetus for this revision.

The WHO states that only 10% of infants in the world are born in hospitals that have earned the Baby-Friendly designation. They do give a nod to the idea that the BHFI is a “vertical” initiative, and this stand-alone “silo” isn’t likely to catch on unless it is surrounded by a bigger community of breastfeeding support.

Also, they mention several times that re-designation is a “challenge.” (Implication: re-designation isn’t happening much.) Yet, despite several attempts, I could not find any statistics to support that assertion. I also saw no research to substantiate why re-designation might be happening. The WHO did allude to the idea that the first attempt at designation is fueled by enthusiasm and key people. Thereafter, the people and the motivations may change. But still, no hard data on that.

Without an understanding of why they re-wrote the recommendations and implementation guidelines,I can’t tell what these guidelines really mean in real life. (And I especially wonder for myself, since I teach a course for hospitals that are pursuing the BFHI designation.)

I am undecided

It’s a lengthy document. I have read most of it, skimmed some of it, and read a few sections several times.

Page 43 has a good comparison table between the “old” and the “new” Ten Steps. Authors say they changed words to reflect “current evidence.” Okay, but I’m troubled by some of the verbs which seem very lightweight to me, and highly subjective. (For example, “encourage.” What does or doesn’t constitute “encouragement” bothers me a lot!)

So, the bottom line is that I haven’t yet fully understood the subtleties of this document. Stay tuned! I’ll try to determine if the revisions are better or worse than the original, at least in my tiny part of the world.

Have you seen it? Do you think the revisions better or worse than the original document? Please comment below! I value your opinion.

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  1. Stephanie Krasner

    Hi Marie,

    I’m not in a hospital setting, and I have not heard about this. Thank you for bringing it to my attention. I’ll be interested to read your follow up (if and when).

    I always appreciate your candor, and keeping us abreast (no pun intended!) of what is current in the lactation world.

    Stephanie IBCLC

  2. Marie

    Stephanie, great to hear from you, as always! And glad to know that, even as a non-hospital person, you’re tuned in to this topic. I think the WHO/UNICEF did give a pitch that having it as just hospital (the “silo” effect, as they said) isn’t going to cut it. The involvement from community needs to be there.

    Thanks, too, for the feedback. I’ve been delaying on commenting on this, since I honestly don’t have it all figured out yet, but felt that I just needed to say…uh, this is a lot of pages to wade through to figure out what the subtle implications this might have.

    And yes, I DO try to keep my faithful subscribers “abreast” of this sort of thing! Good pun, Stephanie!

  3. Gail McClain

    I never read the first nor the second, but I was expected to implement the first while working in a hospital. Many nurses felt like if they didn’t do what was recommended, they would be at least scolded, if not punished, and felt some of the directives about breast feeding were too extreme, hence the labeling of our in-house lactation consultants as “nipple Nazis.” If patients didn’t want to, and most have made up their mind prior to giving birth, many of us didn’t feel it was our job or even the right thing to do to pressure, shame or pitch/persuade the mother into breast feeding. I encountered mothers who were in tears and defensive because they didn’t want to breast feed but they were made to feel like unfit mothers by the “nipple Nazis.” Most women know breast feeding is best for babies, but as long as we promote it in terms of the benefits of doing it instead of the risks of not doing it, fewer will be persuaded. Cultural attitudes must change, too, and that’s where community-level implementation could work. Breasts and babies suckling at them must be viewed as something normal that everyone does. Changing that in the U.S., a country where breasts, especially nipples, are sexual, vulgar objects, will be tough. California had to pass a law allowing mothers to breast feed in public an not be arrested for indecent exposure! What’s really needed is normalizing public breastfeeding, not hospitals insisting on it. I try to discuss this with my nursing students.

    • Marie

      You highlight a few truly important points. First, the Baby-Friendly Hospital Initiative (BFHI) or any other initiative or program or anything else is not well-received when it is seemingly forced upon any. Staff, patients, or anyone. Without a doubt, I’d agree, “normalizing” breastfeeding (in public or anywhere else) is needed. However, you mention that “hospitals insisting” is yet another story. Because if it were fetal monitoring or cardiac rehabilitation or physical therapy after an injury, hospitals would insist on best practices. Oddly, when hospitals insist on best practices for breastfeeding, there’s a lot of angst and name-calling, as you pointed out. So we need to either start trying to “insist” on the normalization of breastfeeding, or we need to wait until the culture spontaneously creates the normalization. (Or somewhere in between; we try to foster the normalization of breastfeeding, rather than wait for it to spontaneously occur.

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