To ensure that all mothers and newborns receive the best quality of care, as embodied in the Baby Friendly Hospital Initiative (BFHI) practices, World Health Organization (WHO) guidance emphasizes the importance of expanding coverage of the Ten Steps globally. To this end, the WHO recommends that the Ten Steps be integrated into national policies and quality improvement programs at the national level (WHO & United Nations Children’s Fund ([UNICEF], 2018). This ambitious goal poses challenges and barriers for BFHI coordinators, and multiple strategies are being applied to address them.
Members of the BFHI Network periodically share information on these issues, among others, in the biannual survey that precedes our in-person meetings (Hernández-Aguilar, 2023). Some of the feedback we received in our 2022 survey covers challenges and barriers to implementing the Ten Steps into national policy and improvement strategies and is presented here. We have grouped responses into five categories (the words quoted are the original words of members—some are non-native English speakers):
Problems with political views or support: “Breastfeeding is seen as a non-feminist behavior and therefore should not be supported,” “Strong bottle culture,” “Breastfeeding is not a priority for health authorities,” “Lack of awareness of the importance and impact of implementing the Ten Steps and the BFHI to support breastfeeding,” “Breastfeeding is seen as a problem only for low-income countries,” and “Health authorities are unwilling to get involved in breastfeeding support.”
COVID restrictions and fears: “The BFHI program is affected by funding restrictions due to COVID” and “COVID imposed restrictions on care, parental access and accompaniment, and staff shortages.”
Human resource challenges: “Lack of [breastfeeding] competent health workers,” “Midwives are no longer required to have breastfeeding education,” “No pre-service breastfeeding education for nurses or doctors,” “Shortage of midwives,” and “Difficulties in funding breastfeeding education.”
Pressure of the commercial infant formula industry: “Conflicts of interest between the infant formula industry and professional associations” and “Hospitals and health professionals under pressure from industry.”
Lack of specific resources: “Lack of WHO materials to implement the 2018 guidelines, especially assessment tools.”
A summary of the strategies used to overcome barriers vary depending on available resources:
Integrating the BFHI into other strategies: “promoting the BFHI as a quality improvement strategy for maternal and child health care” and “partnering the BFHI with other quality improvement strategies, such as the Network of Health Promoting Hospitals, other nutrition programs, or minority protection programs.”
Training Health Professionals: “Train BFHI champions to then expand the strategy to hospitals” and “Educate health care workers about The Code before enforcing its implementation.”
Marketing: “Publicly celebrate the progress made by maternity facilities in implementing the BFHI,” “Hire social media, public relations or press officers to promote breastfeeding, the Ten Steps, and the BFHI,” “Work with government to advocate the importance of implementing the BFHI throughout the health care system, from maternity to community,” “Organize conferences and workshops to raise awareness among health care professionals,” and “Raise awareness among families.”
Supporting maternity facilities: “Ensure that midwives and breastfeeding specialists are available in maternity units,” “Support the BFHI through a national strategy and a national program with a specific budget,” “Require public reporting of breastfeeding indicators,” and “Include BFHI indicators in national accreditation indicators.”
The next meeting of the BFHI Network will be held in April, in Lille France. We look forward to reporting further on the progress BFHI leads have made in overcoming the challenges faced.
María-Teresa Hernández-Aguilar, MD, MPH, PhD, IBCLC
BFHI Network Chairinternational@ihan.es
