1. Updating evidence for the WHO Baby Friendly Hospital Initiative
Mother and Infant Research Unit
Updating evidence for the WHO Baby Friendly Hospital Initiative
Alison McFadden, Senior Research Fellow,
Director, Mother and Infant Research Unit, University of Dundee

3. 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
2017: Updated guidance published

4. New WHO/UNICEF guidance
Scope
Maternity facilities only
Includes preterm and low birthweight newborns
Two aspects
Guidelines on patient care (Ten Steps)
Implementation guidance for national programmes (BFHI)

5. Guidance on patient care
Key inputs
21 literature reviews on Ten Steps
Systematic reviews of women’s values and preferences
Systematic review of providers’ perspectives

6. http://www. cochranelibrary

7. Enabling breastfeeding for women and babies
Support for breastfeeding women
Support for healthy breastfeeding mothers with healthy term babies
Health promotion and enabling environment
Interventions for promoting the initiation of breastfeeding
Education and training of healthcare staff
Care for breastfeeding women and their babies
Treatment of breastfeeding problems
Feeding practices for preterm babies/babies with additional needs and their mothers

8. http://onlinelibrary. wiley. com/doi/10. 1002/14651858. CD001688

9. Background near universal initiation rates
High Income Countries
Low and Middle Income Countries
near universal initiation rates
low rates of initiation within first hour after birth
World average 44%
India 23.3%
Pakistan 18.4%
low initiation rates overall
particularly among women in lower income groups
Norway 95%
UK 81%
US 79%
France 63%,
ROI 55%

10. Background Interventions
Health education, peer support, practical skills training and early mother and baby contact
Address structural, societal, health system, individual and economic influences to the decision to breastfeed
Can be targeted at women, families, wider communities/society or healthcare staff

11. Objectives Effectiveness of breastfeeding promotion activities on
number of women who initiate breastfeeding.
number of women who initiate breastfeeding within one hour after birth

12. Methods Search conducted 29 Feb 2016 Study eligibility
Randomised controlled trials
any breastfeeding promotion intervention
any population group except women and infants with a specific health problem.

13. Results: study settings4 20 1 1 1
28 included trials of 107,362 women in seven countries
24 initiation (USA, UK, Nicaragua)
3 early initiation (Malawi, Nigeria, Ghana) 1
28 trials women 7 countries

14. Breastfeeding Education
Delivered by healthcare professionals improved breastfeeding initiation
RR 1.43, 95% CI 1.07 to 1.93 (5 trials, 564 women)
Delivered by non-healthcare professionals (support/counselling by peer supporters, doulas, lactation educators, trained credit officers, community health workers)
1. Improved initiation
RR 1.22, 95% CI 1.06 to 1.40 (8 trials, 5712 women)
2. Positive non–significant effect on early initiation
RR 1.70, 95% CI 0.98 to 2.95 (2 trials, women)

15. Other interventions No evidence of improved initiation
Breastfeeding education delivered by healthcare professionals with peer support (1 trial of 390 adolescent women)
Breastfeeding education delivered by multi-media (self-help manual, video) (2 trials of 497 women)
Early mother-infant contact (2 trials of 309 women)
Community-based support groups (1 trial, women)

16. Conclusions Low-quality evidence
healthcare professional-led breastfeeding education and/or non- healthcare professional-led counselling and/or peer support can improve breastfeeding initiation
majority of trials were conducted in the USA, among women on low incomes and who varied in ethnicity and feeding intention - limits the generalisability of results to other settings

17. http://onlinelibrary. wiley. com/doi/10. 1002/14651858. CD001141

18. Background
High Income Countries
Low and middle income countries
In some countries - marked decline in breastfeeding after first few weeks
Low rates of exclusivity up to 6 months and continuation beyond 12 months
Generally higher rates of breastfeeding duration than in HICS
Variable rates of exclusive breastfeeding for 6 months
World average 37%

19. Background Interventions
Support - complex intervention to address multi-faceted barriers to breastfeeding
Information/education – e.g. to dispel myths
Skills to manage breastfeeding – positioning and attachment, solving problems
Confidence and esteem-building
Practical support – help with other tasks
Social support – creating supportive networks

20. Objectives
To assess the effectiveness of support for breastfeeding of healthy mothers with healthy babies
Timing and setting of interventions
Different modes of support – proactive/reactive; face-to-face/telephone; antenatal/postnatal;
Different care providers
Interaction between support interventions and background initiation rates

21. Methods Search conducted 29 Feb 2016 Study eligibility
Randomised controlled trials
Comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care

22. Study settings and participant numbers

23. Effect of all types of support on any breastfeeding
Cessation of any breastfeeding before 4-6 weeks
Breastfeeding support reduces number of women stopping breastfeeding before weeks (33 trials with 10,776 women)
RR 0.86, 95% CI 0.79 to 0.93 (31.4% vs 35.3%)
Cessation of any breastfeeding up to 6 months
Breastfeeding support reduces number of women stopping breastfeeding before 6 months (40 trials with 14,227 women)
RR 0.89, CI 0.85 to 0.93 (50.5% vs 57.3%)

24. Effect of all types of support on exclusive breastfeeding
Cessation of exclusive breastfeeding before 4-6 weeks
Breastfeeding support reduces number of women stopping exclusive breastfeeding before 4-6 weeks (32 studies with 10,271 women)
RR 0.79, 95% CI 0.69 to 0.89 (55.4% vs 64.2%)
Cessation of exclusive breastfeeding up to 6 months
Breastfeeding support reduces number of women stopping exclusive breastfeeding before 6 months (46 studies with 18,303)
RR 0.89, 95% CI 0.86 to 0.93 (74.9% vs 82.3%)

25. Sub-group analyses
Lay support may be more effective than professional or mixed support (exclusive breastfeeding before 6 months)
Face-to-face support may be more effective than other types of support
Antenatal component vs postnatal only made no difference
Greater effect on exclusive breastfeeding in settings with breastfeeding initiation >90%

26. Conclusions All women should be offered breastfeeding support.
Support that is provided either only in the postnatal period or in both the antenatal and postnatal period is effective.
Support may be offered either by professional or lay/peer supporters, or a combination of both.
Support for exclusive breastfeeding is likely to be more effective in settings with high initiation rates, so efforts to increase the uptake of breastfeeding should be in place.
Strategies that rely mainly on face-to-face support may be more likely to succeed for women practising exclusive breastfeeding.

27. https://internationalbreastfeedingjournal. biomedcentral

28. Background
Healthcare staff need Knowledge – health outcomes, physiological processes Attitudes – positive, non-judgemental Skills – communication, information provision, practical skills Evidence that many staff don’t have these Lack of evidence of what works to equip staff with above e.g. no RCTs Previous SR have examined effect of staff training on breastfeeding rates but not on knowledge, attitudes or skills

29. Objective To determine whether: Secondary outcomes- BFHI, the Code
education and training programmes for supporting breastfeeding women (intervention)
have an effect on knowledge and attitudes (primary outcomes)
of healthcare staff (population)
compared to not training/usual training (comparator)
Secondary outcomes- BFHI, the Code

30. Results 4 trials (6 papers) of 263 participants
Participants: midwives and postnatal nurses (1), health visitors (1), paediatricians, obstetricians and nurses (1), not clear (1)
Settings: Brazil (2), Denmark (1), Sweden (1)
Interventions: WHO 18-hour course (1), WHO 40-hour course (1), WellstartTM Lactation programme (1), developed process orientated programme (1)
Outcomes: knowledge (3), attitudes (2) – measured at different times, different instruments (none validated), follow-up in intervention group only (2)

31. Results Unable to do meta-analysis,
All studies high or unclear risk of bias
1. Breastfeeding knowledge: 2 studies (Kronborg 2008; Rea 1999)
Small but significant positive effects in the healthcare staff receiving the intervention
2. Breastfeeding attitudes: 2 studies (Ekstrom 2005; Kronborg 2008)
Inconsistent findings – small but significant effect of some measures

32. Results
Secondary outcomes 1. Compliance with BFHI – 1 study (Rea 1999) Health visitors who received the 18 hour WHO course were significantly more likely to perform a demonstration of how to breastfeed to mothers 2. Adherence to the Code - no studies

33. Conclusions
Lack of good quality evidence on whether breastfeeding training and education for healthcare staff can help improve breastfeeding knowledge and attitudes
Small but significant positive effects for measures of knowledge, some measures of attitudes, and performance of BFHI step five
Evidence extremely limited (few trials, poor quality)
Has implications for effectiveness of breastfeeding support interventions

34. Summary
1. Breastfeeding support extends the length of any and exclusive breastfeeding
2. Professional-led breastfeeding education and lay counselling and peer support can promote initiation of breastfeeding
3. Lack of evidence on whether breastfeeding training and education for healthcare staff improves breastfeeding knowledge and attitudes

35. @AlisonMcFDundee @MIRU_UK
Mother-to-mother support groups in the community, accompanied by communication strategies to promote breastfeeding, using multiple channels and messages tailored to the local context
@AlisonMcFDundee @MIRU_UK