Presentation for the 9th IBFAN Africa Regional Conference THE BABY FRIENDLY HOSPITAL INITIATIVE STATUS IN SWAZILAND Kwanele Simelane Programme Director Swaziland Infant Nutrition Action Network Presentation for the 9th IBFAN Africa Regional Conference

Presentation Outline History and Progress of BFHI in Swaziland Achievements so far Challenges

BFHI was launched by WHO and UNICEF in 1991 following the Innocenti declaration of 1990. Aim: promote, protect and support breastfeeding practices in health care facilities. By early 1992 Swaziland had established the National BFHI Task Force. Trainings commenced in 1992 spearheaded by SINAN. The first BFHI external assessment was conducted in 1994. Four facilities out of six attained the Baby Friendly status.

However the HIV scourge which was at 46 However the HIV scourge which was at 46.2% among pregnant women (MOH,2006) reversed the gains in child health and survival as there was growing evidence of the presence of HIV in breast milk, putting breastfeeding babies at risk of contracting the HI virus. The Swaziland Demographic Health Survey was conducted in 2007 which reported that about 87% of infants initiate breastfeeding, 67% within the 1st hour; however 19% reported to have received pre- lacteal feeds, Exclusive breastfeeding went down to 53% at one month, a sharp decline of 17% at 6 months.

It was deemed necessary to assess the BFHI status in hospitals and health care centres, (DHS, 2007) The SNNC in collaboration with SINAN and UNICEF conducted in service education on safe infant feeding practices to clinical and non-clinical staff using the WHO/UNICEF training curriculum. Once hospitals and health centres had been trained, they conducted self-assessment using the BFHI Self-Appraisal Tool. Health centres (Sithobela, Nhlangano, Mkhuzweni, Dvokolwako and Matsanjeni) and 3 hospitals (Mbabane Government, RFM and Piggs peak were assessed. The whole performance of facilities was average.

In 2009, all the public facilities in Swaziland were assessed for Baby Friendly Status. This included all 5 health centres listed above and 6 hospitals These assessments saw 10 out of 11 facilities attaining the Baby Friendly Status. This success could easily be linked to the improvement in exclusive breastfeeding rates for the country which rose from an average of 32% (MICS,2000) to 44% (MICS,2010).

With the high staff turnover and ward rotations there was a need to re-orient the staff on BFHI so as to re-assess and hopefully improve the infant feeding practices. It was also vital to capacitate the private facilities since they have been largely left out of public health interventions .

In 2013, a 3 day training of trainers (TOT) on BFHI was conducted for health care workers under in-service, nutrition and quality assurance departments. In 2014, on site trainings were conducted in 11 public facilities and 3 private clinics. After the trainings, each facility established breastfeeding/BFHI committee that coordinates all BFHI issues. The committees were responsible for developing and translating facility breastfeeding policies which were then printed with the help of SNNC and UNICEF. The committees were also responsible for preparing the facility for an external assessments.

Early 2015, an external assessment was done by a pull of intensively trained assessors. The assessments included all 11 public facilities and 2 private clinics. 3/13 were able to reach the minimum standard of BFHI accreditation, 1 being a private clinic, 5 received certificates of commitment and 5 failed the assessments. Again with this initiative, other interventions and strategies, exclusive breastfeeding rates were increased from 44% (MICS, 2010) to 63.8% MICS (2015). Exclusive breastfeeding is more important now than ever with the current recommendations on HIV and Infant feeding.

Achievements so far The country has started the process of incorporating the BFHI steps as indicators into the National Quality Assurance and Control Tool for routine monitoring and reporting. The initiative is embraced by private facilities and 1 of them has passed the last assessment. Facilities have breastfeeding committees in place to make sure the set up policies are implemented The National Food and Nutrition Policy has been finalised and it gives direction on MIYCN in facilities.

The National Infant and Young Child Feeding Guideline gives optimal support for HIV positive mothers. Most importantly: Exclusive breastfeeding rates have increased from 44.1 % (MICS 2010) to 63.8% (MICS 2015).

Challenges Resources remain the main challenge in moving the BFHI agenda forward. It takes a long time to do assessments and follow up supervision then facilities end up losing focus. Staff turn over and reshuffling remains a big challenge to facilities in implementing the BFHI practices. Community support for breastfeeding mothers is still lacking in the country