Baby-Friendly Hospital Initiative - Revised, Updated and Expanded For Integrated Care - Section 1 - Background and Implementation - 0

BABY-FRIENDLY HOSPITAL INITIATIVE:
Revised, Updated and Expanded for

Integrated Care
SECTION 1
BACKGROUND AND IMPLEMENTATION
Preliminary Version for Country Implementation

January 2006
Original BFHI Guidelines developed 1992
WHO Library Cataloguing-in-Publication Data
Baby-friendly hospital initiative [electronic resource] : rev., updated and expanded for integrated
care. -- Preliminary version for country implementation.
1 web site.
Produced by the World Health Organization and UNICEF.

Contents: Section 1. Background and implementation -- Section 2. Strengthening and
sustaining the baby-friendly hospital initiative : a course for decision-makers -- Section 3.
Breastfeeding promotion and support in a baby-friendly hospital : a 20-hour course for maternity
staff -- Section 4. Hospital self-appraisal and monitoring -- Section 5. External assessment and
reassessment (Restricted document - available upon request).
1.Breast feeding. 2.Hospital administration. 3.Maternal welfare. 4.Program evaluation.

I.World Health Organization. II.UNICEF.
ISBN 92 4 159501 9 (NLM classification: WQ 27.1)

978 92 4 159501 8
Cover image “Maternity”, 1963,

© 2003 Estate of Pablo Picasso/Artists Rights Society (ARS), New York
© United Nations Children’s Fund December 2005

© World Health Organization 2006
Reproduction and translation: Applications for permission to reproduce or translate all or part
of this publication should be made to the local UNICEF Representative. Consultation with
UNICEF/PD/Nutrition is advisable when considering translation so as to prevent duplication of
effort.
UNICEF contact email: [email protected] with the subject: attn. nutrition section
WHO contact email: [email protected] Website: http://www.who.int/nutrition
Reference this document as: UNICEF/WHO. Baby Friendly Hospital Initiative, revised, updated
and expanded for integrated care, Section 1, Background and Implementation, Preliminary
Version, January 2006
UNICEF/WHO BFHI materials: Revised, Updated and Expanded for Integrated Care 2006
Acknowledgements
The original1992 BFHI guidelines were prepared by the staff of the United Nations Children's
Fund (UNICEF), the World Health Organization (WHO), with assistance from Wellstart
International in developing The Global Criteria.
This revision of the BFHI Background and Implementation Guidelines was prepared by:
Section 1.1: Miriam Labbok, Senior Advisor, Infant and Young Child Feeding and Care,
UNICEF NYHQ
Section 1.2: Ann Brownlee, UCSD, as a consultant of BEST Services
Section 1.3: Ann Brownlee, UCSD, as a consultant of BEST Services
Section 1.4: David Clark, Legal Programme Officer, UNICEF NYHQ
UNICEF NYHQ
UNICEF NYHQ, and Genevieve Becker, BEST Services
Acknowledgement is given to all the UNICEF and WHO Regional and Country offices, BFHI
coordinators, health professionals, and field workers, who, through their diligence and caring,
have implemented and improved the Baby-friendly Hospital Initiative through the years, and
thus contributed to the content of these revised guidelines.
The extensive comments provided by Genevieve Becker and Ann Brownlee of BEST Services;
Rufaro Madzima, MOH Zimbabwe; Mwate Chintu, LINKAGES Project; Miriam Labbok, UNICEF
and Randa Jarudi Saadeh, WHO were of particular value.
Review and additional inputs were provided by: Azza Abul-Fadl Egypt; Carmen Casanovas,
Bolivia; Elizabeth Hormann; Germany; Elizabeth (Betty) Zisovka, Macedonia; Ngozi Niepuome,
Nigeria; and Sangeeta Saxena, India.
Acknowledgements for all those who assisted with reviewing the Global Criteria and other
components of the BFHI package that relate to self-appraisal and assessment are listed in
Sections 4 and 5 of the set of materials.
Special thanks to the many government and NGO staff, members of National Authorities, and
BFHI national co-coordinators around the world who responded to the User Needs survey and
gave further input concerning revisions to the assessment tools and generously shared various
BFHI self-appraisal and assessment tools developed at country level.
These multi-country and multi-organizational contributions were invaluable in helping to fashion

a set of tools and guidelines designed to address the current needs of countries and their
mothers and babies, facing a wide range of challenges in many differing situations.
Preface for the 2005/6 BFHI materials:
Revised, Updated and Expanded for Integrated Care
Preliminary Version for Country Implementation
Since the Baby-friendly Hospital Initiative (BFHI) was launched by UNICEF and WHO
in 1991-1992, the Initiative has grown, with more than 19,600 hospitals having been
designated in 152 countries around the world over the last 15 years. During this time, a
number of regional meetings offered guidance and provided opportunities for
networking and feedback from dedicated country professionals involved in
implementing BFHI. Two of the most recent were held in Spain, for the European
region, and Botswana, for the Eastern and Southern African region. Both meetings
offered recommendations for updating the Global Criteria, related assessment tools, as
well as the “18 hour course,” in light of experience with BFHI since the Initiative
began, the guidance provided by the new Global Strategy for Infant and Young Child
Feeding, and the challenges posed by the HIV pandemic. The importance of addressing
“mother-friendly care” within the Initiative was raised by a number of groups as well.
As a result of the interest and strong request for updating the BFHI package, UNICEF,
in close coordination with WHO, undertook the revision of the materials in 2004-2005,
with Genevieve Becker of BEST Services taking the lead on revision of the course and
Ann Brownlee, University of California/San Diego, spearheading the revision of the
assessment tools. The process included an extensive “user survey” with colleagues from
many countries responding. Once the revised course and tools were drafted they were
reviewed by experts worldwide and then field-tested in industrialized and developing
country settings.
The current BFHI package1 includes:
Section 1: Background and Implementation, which provides guidance on the revised

processes and expansion options at the country, health facility, and community level,
recognizing that the Initiative has expanded and must be mainstreamed to some extent
for sustainability, and includes:
1.1 Country Level Implementation
1.2 Hospital Level Implementation
1.3 The Global Criteria for BFHI
1.4 Compliance with the International Code of Marketing of Breastmilk Substitutes
1.5 Baby-Friendly Expansion and Integration Options
1.6 Resources, References and Websites
Section 2: Strengthening and sustaining the Baby-friendly Hospital Initiative: A course
for decision-makers was adapted from WHO course "Promoting breast-feeding in
health facilities a short course for administrators and policy-makers". This can be used
to orient hospital decisions-makers (directors, administrators, key managers, etc.) and
policy-makers to the Initiative and the positive impacts it can have and to gain their
commitment to promoting and sustaining "Baby-friendly". There is a Course Guide and
eight Session Plans with handouts and PowerPoint Slides. Two alternative session plans
and materials for use in settings with high HIV prevalence have been included.
1
Sections 1 through 4 are available on the UNICEF Internet at http://www.unicef.org/nutrition/index_24850.html, or
by searching the UNICEF Internet site: http://www.unicef.org or the WHO Internet at www.who.int/nutrition
Section 3: Breastfeeding Promotion and Support in a Baby-Friendly Hospital, a 20-hour
course for maternity staff, which can be used by facilities to strengthen the knowledge
and skills of their staff towards successful implementation of the Ten Steps to
Successful Breastfeeding. This section includes:
3.1 Guidelines for Course Facilitators including a Course Planning Checklist
3.2 Outlines of Course Sessions
3.3 PowerPoint Slides for the Course
Section 4: Hospital Self-Appraisal and Monitoring, which provides tools that can be
used by managers and staff initially, to help determine whether their facilities are ready
to apply for external assessment, and, once their facilities are designated Baby-
Friendly, to monitor continued adherence to the Ten Steps. This section includes:
4.1 Hospital Self-Appraisal Tool
4.2 Guidelines and Tool for Monitoring
Section 5: External Assessment and Reassessment2, which provides guidelines and

tools for external assessors to use to both initially, to assess whether hospitals meet the
Global Criteria and thus fully comply with the Ten Steps, and then to reassess, on a
regular basis, whether they continue to maintain the required standards. This section
includes:
5.1 Guide for Assessors
5.2 Hospital External Assessment Tool
5.3 Guidelines and Tool for External Reassessment
2
Section 5: External Assessment and Reassessment, is not available for general distribution. It is only provided to the
national authorities for BFHI who provide it to the assessors who are conducting the BFHI assessments and
reassessment
SECTION 1
BACKGROUND AND IMPLEMENTATION
Page
1.1 Country Level Implementation and Sustainability
Background Rationale for Revisions 1
Getting Started 3
Five Steps in Implementing BFHI at the Country Level 4
National Criteria for Baby-friendly Community Designation 13
Annex 1: Suggested questions for a rapid baseline country assessment 14
Annex 2: Excerpts from recent WHO, UNICEF, or other global publications
or releases 17
Annex 3: The contribution of breastfeeding and complementary feeding
to achieving the Millennium Development Goals 19
1.2 Hospital Level Implementation

Breastfeeding rates 21
Supplies of Breastmilk Substitutes 21
HIV and Infant Feeding 22
Mother-friendly Care 23
The Baby-friendly Hospital Designation Process 23
1.3 The Global Criteria for the BFHI

Criteria for the 10 Steps, the Code, and optional components 26
Annex 1: Acceptable medical reasons for supplementation (DRAFT) 37
1.4 Compliance with the International Code of Marketing of

Breast-milk Substitutes 39
1.5 Baby-friendly Expansion and Integration Possibilities

Baby-friendly communities: Recreating Step Ten 43
BFHI and Prevention of Mother to Child Transmission of HIV/AIDS 47
Mother-Baby friendly facilities and communities 47
Baby-friendly Neonatal Intensive Care and Paediatric Units 49
Baby-friendly Physician’s Office 50
Baby-friendly Complementary Feeding 51
Mother-baby friendly health care – everywhere 54
1.6 Resources, References and Websites 55
1
SECTION 1.1:
COUNTRY LEVEL IMPLEMENTATION
Background Rationale for Revisions

When the Baby-friendly Hospital Initiative was conceived in the early 1990s, in
response to the Innocenti Declaration’s call for action, there were very few countries
that had dedicated Authorities or Committees to oversee and regulate infant feeding
standards. Today, after nearly 15 years of work in support of optimal infant and young
child feeding, more than 150 countries have, at one time or another, assessed hospitals
and designated at least one facility “Baby-friendly.” While the BFHI has measurable
and proven impact,3 it is clear that only a comprehensive, multi-sector, multi-level effort
to protect, promote and support optimal infant and young child feeding can hope to
achieve and sustain the behaviours and practices necessary to enable every mother and
family to give every child the best start in life.
The 2002 WHO/UNICEF Global Strategy for Infant and Young Child Feeding
(GSIYCF) calls for renewed support - with urgency - for exclusive breastfeeding from
birth for 6 months, and continued breastfeeding with timely and appropriate
complementary feeding for two years or longer. This Strategy and the associated
“Planning Framework for Implementation” being prepared by WHO and UNICEF
reconfirm the importance of the Innocenti Declaration goals, while adding attention to
support for complementary feeding, maternal nutrition, and community action.
The nine operational areas of the Global Strategy are:
1. Appoint a national breastfeeding co-ordinator, and establish a breastfeeding
committee;
2. Ensure that every maternity facility practices the Ten Steps to Successful
Breastfeeding;
3. Take action to give effect to the International Code of Marketing of Breast-milk
Substitutes and subsequent relevant resolutions of the World Health Assembly;
4. Enact imaginative legislation protecting the breastfeeding rights of working
women;
5. Develop, implement, monitor and evaluate a comprehensive policy covering all
aspects of infant and young child feeding;
6. Ensure that the health care system and other relevant sectors protect, promote
and support exclusive breastfeeding for six months and continued breastfeeding
for up to two years of age or beyond, while providing women with the support
that they require to achieve this goal, in the family, community and workplace;
7. Promote timely, adequate, safe and appropriate complementary feeding with
continued breastfeeding;
8. Provide guidance on feeding of infants and young children in exceptionally
difficult circumstances, which include emergencies and parental HIV infection;
9. Consider what new legislation or other suitable measures may be required to give
effect to the principles and aim of the International Code of Marketing of Breast-
milk Substitutes and to subsequent relevant World Health Assembly resolutions.
3
Kramer MS, Chalmers B, Hodnett ED, et al: PROBIT Study Group (Promotion of Breastfeeding Intervention Trial) Promotion of
Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus .JAMA. 2001 Jan 24-31;285(4):413-20.
and Merten S, Dratva J, Ackermann-Liebrich U. Do baby-friendly hospitals influence breastfeeding duration on a national level?
Pediatrics. 2005 Nov;116(5):e702-8.
Section 1.2: Country Level Implementation 2
This implementation plan encourages all countries to revitalize action programmes

according to the Global Strategy, including the Baby-friendly Hospital Initiative (BFHI).
The original BFHI addresses targets 1 and 2 and 8, above, and this version adds some
clarity to 1, 2, 6, 7 and 8.
In 2003, nine UN agencies joined in the development and launching of “HIV and Infant
Feeding - Framework for Priority Action”. This document recommends key actions to
governments related to infant and young child feeding, and covers the special
circumstances associated with HIV/AIDS. The aim of these actions is to create and
sustain an environment that encourages appropriate feeding practices for all infants
while scaling-up interventions to reduce HIV transmission.
The five recommended actions include the need for ensuring support for optimal infant and
young child feeding for all, including the need for BFHI, as requisites to successful
counseling of the HIV-positive mother:
1. Develop or revise (as appropriate) a comprehensive national infant and young
child feeding policy that includes HIV and infant feeding.
2. Implement and enforce the International Code of Marketing of Breast-milk
Substitutes and subsequent relevant World Health Assembly Resolutions.
3. Intensify efforts to protect, promote and support appropriate infant and young
child feeding practices in general, while recognizing HIV as one of a number of
exceptionally difficult circumstances.
This action specifically includes a call for revitalization and scale-up of
coverage of the Baby-friendly Hospital Initiative and extend it beyond hospitals,
including through the establishment of breastfeeding support groups. It also
encourages making provision for expansion of activities to prevent HIV
transmission to infants and young children hand-in-hand with promotion of
BFHI principles.
HIV/Infant Feeding counseling training recommendations from WHO/UNICEF
note that BFHI or other breastfeeding support training should precede training
on infant feeding counseling for the HIV-positive mother.
4. Provide adequate support to HIV-positive women to enable them to select the
best feeding option for themselves and their babies, to successfully carry out
their infant feeding decisions.
5. Support research on HIV and infant feeding, including operations research,
learning, monitoring and evaluation at all levels, and disseminate findings.
BFHI Section 1, Background and Implementation, presents a methodology for
achieving the purpose of the BFHI – to encourage and facilitate the transformation of
the hospital facilities in accordance with the WHO and UNICEF “Ten Steps to
Successful Breastfeeding.” The original 1992 documents have been revised to take into
account the current global context, with consideration given to HIV/AIDS, to address
obstacles to the processes that have been encountered over the years, and include recent
evidence-based findings related to infant and young child feeding.
Getting Started
Numerous countries have already taken steps to start national Baby-friendly campaigns,
including vigorous steps toward improved support to breastfeeding in hospitals, actions
to protect breastfeeding by national policy implementation, and public promotion
campaigns. The recommendations and steps below are presented to perhaps modify and
to strengthen, not to replace, such national initiatives. They indicate how the
achievements of strong national programmes may be confirmed and recognized
internationally by using the BFHI global process.
The Ten Steps to Successful Breastfeeding, a summary of the guidelines for maternity
care facilities presented in the Joint WHO/UNICEF Statement Protecting, Promoting and
Supporting Breastfeeding: The Special Role of Maternity Services, (WHO,1989) have been
accepted as the minimum global criteria for attaining the status of a Baby-friendly Hospital.
TEN STEPS TO SUCCESSFUL BREASTFEEDING
Every facility providing maternity services and care for newborn infants should:
1. Have a written breastfeeding policy that is routinely communicated to all
health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of
breastfeeding.
4. Help mothers initiate breastfeeding within a half-hour of birth.
5. Show mothers how to breastfeed, and how to maintain lactation even if they
should be separated from their infants.
6. Give newborn infants no food or drink other than breastmilk unless
medically indicated.
7. Practise rooming in - allow mothers and infants to remain together - 24 hours
a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to
breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers
to them on discharge from the hospital or clinic.
The process of becoming a baby-friendly hospital is outlined in Section 1.2. In brief, it

is a process that starts with self-appraisal by the hospital. This initial self-assessment
will lead to analysis of the practices that encourage or hinder breastfeeding, and then to
action to make the necessary changes. It thus follows the triple-A sequence
(Assessment, Analysis, Action), which characterises other UNICEF Programme
development. After a facility is satisfied that it meets a high standard, this achievement
is confirmed objectively by an external assessment of whether the facility has achieved,
or nearly achieved, the “Global Criteria” for BFHI and thus can be awarded the Global
Baby-friendly Hospital designation and plaque.
UNICEF and WHO, with the technical assistance of BEST Services and many
reviewers, have revised the key documents that will serve to guide the Baby-friendly
Hospital Initiative, including guidelines for implementation of the Initiative in Section
1, including initiation at the country and hospital levels, guidelines for complying with
the International Code of Marketing, and ways to increase sustainability and the reach
of services; Section 2: Strengthening and sustaining the Baby-friendly Hospital
Initiative: A course for decision-makers was adapted from WHO course "Promoting
breast-feeding in health facilities a short course for administrators and policy-makers";
Section 3: the BFHI Training Course; and Sections 4 and 5, with tools for self-appraisal,
monitoring, and external assessment.
Five Steps in Implementing BFHI at the Country Level

Today many countries’ BFHI programmes are well underway. Therefore, this section
will offer a five step approach, based on those in use for more than a decade, with
modifications for today’s circumstances. This section addresses both those settings
where there is no BFHI or it has become quiescent, as well as those where the BFHI
effort is ongoing. Each step includes suggested activities. These five essential steps in the
process, and the inputs and outputs associated with them, are summarised on page 12.
Step 1:
Establish, re-energize, or plan a meeting of the National Breastfeeding, Infant and
Young Child Feeding, or Nutrition Authority, to establish or assess its functions
related to BFHI.
If your country has an established national authority, ensure that it is up to the current
standards as outlined in the Global Strategy for Infant and Young Child Feeding. If not,
the following provides guidance for its membership and functions.
- 1A. Who are the members of a National Authority?
According to the Global Strategy, the national authority should be multi-sectoral. The
National Authority should not be confined to the medical of health sector. Possible
composition would include:
• Representative(s) of the national government’s health and nutrition sector that
supports women and children’s health outcomes,
• Representative(s) of the national government’s financial planning,
• Representative(s) of the national government’s social sector,
• Technical representative(s) from the academic sector,
• Community action leadership, such as NGOs, and
• Representative(s) from committee(s) that supports BFHI and/or Code
implementation
• Communications specialist
• Monitoring and evaluation specialist
- 1B. What is the role of the National Authority in relation to BFHI?

The national authority will have government endorsement to have oversight of all nine
operational targets, as operationalised in the four major action areas: 1) national policy
and legislation, 2) health system standards, reform and related multi-sectoral action, 3)
community action, and 4) special circumstances. As such the primary roles are to:
• strategize and plan IYCF activities,
• oversee implementation of specific activity areas, such as BFHI and the Code of
Marketing, and,
• monitor and evaluate the status of activities, such as programme efforts, and
outcomes in terms of feeding behaviours.
These activities demand ongoing assessment and feedback. Therefore, the national
authority must also advocate for data collection, both ongoing in health systems as well
as periodic surveys. To perform these functions, the national authority should be
mandated by the national or regional government and be fully funded within the ongoing
national or regional budget.
The specific roles and responsibilities of the national authority include:
• coordinating and fostering collaboration across Ministries, stipulating a process
for sustainable reassessment, e.g., via insurance, taxes.
• incorporating support for breastfeeding and complementary feeding into ongoing
mechanisms.
• achieving stated IYCF goals. Therefore, a regular budget and budget line must
be identified by the government from governmental sources to support these
functions.
• setting Goals based on international standards. In general:
- The goal for early initiation should be that newborns are placed skin-to-skin
within minutes of birth, remaining for 60 minutes or longer, with all mothers
encouraged to support the infant to breastfeed when their babies show signs
of readiness.
- The goal for exclusive breastfeeding, as determined at the UN Standing
Committee on Nutrition, 2004, should be to increase exclusive breastfeeding
to 6 months of age to a minimum of 60% by 2015, with the ultimate goal of
nearing 100%.
Note: In countries where women receive voluntary counselling for
HIV/AIDS, a proportion of these women will choose replacement feeding.
Even though some of the HIV-positive women will choose exclusive
breastfeeding, in such settings, the ultimate goal will remain less than 100%.
- The goal for complementary feeding, as determined at the UN Standing
Committee on Nutrition, 2004, from 6 months to 23 months or longer, is that
breastfeeding continue to supply 350-500 calories a day, and an additional 3-5
feedings of nutrient rich complementary foods is needed, as described under
“optimal feeding.”
• overseeing standards for health worker training and legislation to protect optimal
infant and young child feeding, such as undergraduate health worker curricula,
working with professional organizations to upgrade standards of practice, and
legislation to implement the Code of Marketing and maternity protection.
• adapting criteria for Baby-friendly expansion into the community and other
expansion approaches (see section 1.5).
• incorporating baby-friendly principles into any and all related health (e.g.,
Saving Newborn Lives, C-IMCI) or social programmes (e.g., Early Child
Development).
• providing technical oversight of the BFHI Coordination Group’s assessments –
including how it administers self-appraisals, assessments and re-assessment at
least once every 3-5 years.
• overseeing ethics of the designation processes and insure avoidance of conflict
of interest, whether with a manufacturer, training programme, or other, that may
bias assessments and designations.
• carrying out, at least annually, an assessment and evaluation of health service
data on breastfeeding and complementary feeding for baby-friendly-designated
and other settings.
In addition, the National Authority will develop a multi-year plan of action and
associated budget for government support and consideration, and will meet regularly to
assess progress against each goal, as well as to assess progress on agreed upon objectives.
Step 2:
Identify – or re-establish -- national BFHI goals and approaches.
Many countries have BFHI committees and goals in place, but they may or may not be
part of current comprehensive or integrated policies and plans. The first step is to ensure
that these goals are currently part of national or regional programming. If there has not
been recent action on these goals, consider conducting a rapid baseline survey of
country-level breastfeeding and complementary feeding practices, support activities,
and status of facilities that were previously designated to assess current status and
current standards of practice among health professionals. (See the sample questionnaire
for rapid assessment in Annex 1 of this Section 1.1.)
The concept of BFHI is no longer limited to the Ten Steps in maternities, but rather has
many possibilities for expansion into other parts of the health system, including
maternal care, paediatrics, health clinics, and physicians’ offices, and into other sectors
and venues such as community, commercial sector, and agricultural or educational
systems. Baby-friendly Care can also be provided in tandem with other international
initiatives, such as Community IMCI or HIV/AIDS/PMTCT programming.
The National Authority may consider the components and emphases of the greater
picture of Baby-friendly care in the local context. Some examples of these options are
presented later in the Section 1.5: Expansion and Integration Possibilities.
Step 3:
Identify, designate or develop a BFHI Coordination Group (BCG).
This may or may not be considered to be additional role for the National Breastfeeding,
Infant and Young Child Feeding, or Nutrition Authority. However, it is highly
recommended that there be at least two separate groups, both recognized by the
government, so that the National Authority might provide oversight for the activities of
the other, and so that there is a place that a facility might seek recourse if there is any
question concerning the designation process.
- 3A. Who selects the BFHI Coordination Group?

The National Authority, whether located in the Ministry of Health, another Ministry, or as a
government-sanctioned NGO, will designate a BFHI Coordination Group and maintain
oversight with intent to ensure ongoing quality assurance and a code of ethics. The national
government may choose to designate this group, with confirmation by the National Authority.
- 3B. What are the roles of this Group?

The BFHI Coordination Group (BCG) is responsible for coordinating the process and
procedures for facility designation. The BCG itself may or may not carry out the
assessments for designation, depending on the number of facilities in the country, the
structure of the group, and the resources available. Alternatively, the BCG could serve to
ensure that all BFH Designating Committees or Designating Processes use standardized
procedures. (See Step 5)
The BCG is responsible for acquiring the BFH designation posters from the UNICEF
supply catalogue or through locally developed image creation, and for having the BFHI
designation plaques printed in the local language. Specifications for the plaques are
available from UNICEF or WHO representatives.
The BFH Designating Committees (BDCs) are arms of the BCG where needed. These
committees are qualified by the BCG to carry out assessments and recommend facilities
for Designation. “Designation” means the formal recognition by the BCG that there is
conformity with the BFHI Hospital Assessment Criteria (See Section 1.2).
There are at least eight models for development of the BCG and the approach to
assessment and credentialing/designating hospitals and maternities as “Baby-Friendly”:
1. Develop, legislate and regulate standards for health facilities that include the
components of BFHI. In this model, there would be no BCG aside from the
oversight by the National Authority. Legislating BFHI will support sustainability;
however, without activities to ensure the quality of the activity, this model could
result in superficial activities alone. Therefore this model would require ongoing
monitoring and enforcement regulations in the legislation.
2. Incorporate Baby-friendly assessment criteria into national health facility
credentialing board procedures that are national standards for all hospitals and
maternities. In some countries, such credentialing is under the auspices of the
professional societies, in others a separate association is established to provide
quality assurance. In this case, the national board would serve the function of the
BCG, and regular re-credentially would be sustained. This probably is the most cost-
efficient option.
3. Encourage a professional organization or professional network to include BFHI in
its mandate. For example, in Australia, the professional society of nurse-midwifery
is the BCG and is responsible for assessments. This could be with or without
government support. BFHI could, logically, be the responsibility of any health
profession that serves mothers and newborns and could designate, with National
Authority oversight. This model would appear to offer enhanced quality control;
however, some professional societies do not have the structural nor fiscal base to
take on this task.
4. Establish a system whereby facilities assess each other and help each other to
achieve designation status. This model reduces the burden and the costs for the
central authority, in that there only need be spot checks as to ongoing status, and
would lessen the load for the BDC. However, with this reduced direct oversight,
there may be a risk of collusion or other biases.
5. Allow one professional organisation or other NGO, independent of the National
Authority, to take responsibility for designation. This approach, similar to 3, above,
without oversight, may lead to breeches in quality assurance and may result in
conflict of interest, e.g., if the NGO also provides and charges for training, charges
for preparation for assessment, and charges for helping the facility to improve if
they fail the assessment may be practicing with inherent conflict of interest. In some
settings, charges for the assessments may be prohibitive for smaller facilities or
those in poorer settings. This last option is currently functioning in many countries.
An alternative (6 and 7, below) would provide checks and balances for this approach.
6. Allow any interested professional organization or NGO to apply to the National
Authority for the right to coordinate the designation process (BCG) or to serve as a
designating committee (BDC). One or more NGOs could be approved by the
National Authority to create a system of BDCs or carry out the assessments and
designations themselves, depending on the number of facilities and the capacity of
the NGO. The National Authority would be the organization that oversees this and
grants the designations. The possibility of competition between NGOs could be
minimized by regional responsibility and careful oversight (see 7 below).
7. Allow any interested professional organization or NGO to apply to the National
Authority for the right to coordinate the designation process (BCG) or to serve as a
designating committee (BDC) for a specific region of the country. This approach is
similar to 5 and 6 above, however, it includes aspects of oversight while reducing
the possibility of inappropriate competitive activities. This approach may present a
greater administrative burden for the National Authority.
8. While not ideal, UNICEF country offices may assist this function for a very limited
period of time until the National Authority and BCG is established.
Regardless of the approach taken, it is essential that all necessary measures are taken to
avoid a) any compromise to the high standards required for BFHI accreditation and b)
any conflict of interest. Particular care should be taken where the national authority has
given the BFHI designation group responsibility for delivering or monitoring standards
of clinical care, or for delivering general health professional education and/or for
providing specific breastfeeding training. The National Authority (as described above)
is essential for oversight or quality and ethical considerations.
Step 4:
The National Authority A) ensures that the BFHI Coordinating Group fulfils its
responsibility to provide, directly or indirectly, the initial or ongoing assessments of
facilities, B) helps plan training and curriculum revision, C) ensures that national
health information system includes a record of feeding status on all contacts with
children under 2 years of age, D) monitoring and evaluation plan.
Note: If the BFHI program is ongoing, it may not be necessary to carry out all parts of
this step, as there may be an existing record of current status, a roster of trainers and
assessors, and a training plan ongoing, with curriculum revisions being enacted.
However, the BFHI may not as yet include health information system updates to ensure
that feeding status of all children is recorded.
- 4A. Ensuring that the BFHI Coordinating Group fulfils its responsibility to provide,
directly or indirectly, the initial or ongoing assessments of facilities.
Once the National Authority has developed the BCG, initial assessments of current
status of the BFHs should be the next activity. No matter which model of BCG is
instituted, initial assessments should be carried out by specially trained local or external
assessors. Following the assessment or review of current status, establishing if there is a
roster of individuals with expertise to serve as 1) local assessors, 2) trainers for each
level of training, 3) curriculum specialists, and 4) health information system specialists,
plans may be developed to engage these individuals in these tasks. If there is not a
sufficient number of individuals with each of these skill areas, consider holding further
trainings or sending individuals to regional or global training courses.
Current regional and global training courses can be accessed at:
http://www.unicef.org/nutrition/index_events.html or at http://www.who.int or on the
Nutrition Quarterly, last section, found in the right hand column of:
http://www.unicef.org/nutrition/index_bigpicture.html
The National Authority has the authority to modify or change the BCG as needed to
maintain the function of ongoing assessment and designation.
- 4B. Helps plan training and curriculum revision
Once the needs and the rosters are available, the needed curriculum revisions and
trainings should be planned. Based on the assessed needs, a plan should be developed
for carrying out the 20 hour course in every facility as well as for periodically
conducting curricula updates. In addition, special training should be ensured for those
health workers who will serve as the referral expert lactation consultants. The trainings
should be carried out by individuals with appropriate training and skills. It is reasonable
to develop a phased plan, so that those trained in one facility may support trainings in a
near-by site. It is important that there be on-site ongoing training by supervisors, as
well. Therefore, each BFH facility must have on staff individuals with significantly
more training, such as a Certified Lactation Consultant or other certified specialists on
this issue.
If BFHI assessors are available and facilities are ready, assessment may begin
immediately without waiting for the training plans to be implemented. If there is an
insufficient number to carry out assessments, all levels of training, and/or curricula
reform, the plan should address these needs.
Even where few births take place in facilities, training may be necessary to create a
standard of care and to ensure that all health care personnel are skilled in breastfeeding
protection, promotion and support. In addition, consideration should be given to
development of “Baby-friendly” community designation (See Section 1.5), or other
national programme approaches to ensure support for early, exclusive and continued
breastfeeding with age-appropriate complementary feeding. These efforts can be linked
to facilities directly, or through health or social systems, to ensure consistency in
messages and support approaches.
Phased work should begin immediately, with all training materials and curricula updates
developed, and sufficient resources identified to complete this work in a timely manner.
In addition to BFHI materials, National Authorities should consider providing
handbooks such as “Protecting Infant Health: A Health Workers’ Guide to the
International Code of Marketing of Breastmilk Substitutes”, a basic breastfeeding
support manual, and a summary of local regulations, law and policy.
- 4C. Ensuring that national health information system includes a record of feeding
status on all contacts with children under 2 years old
This responsibility will necessitate dealing with the Ministry of Health, academia,
Ministry of Education, Ministry of Plan, and Demographics, depending on which has
the responsibility for data collection. Existing health information systems should be
amended to include the new growth standards of WHO, notation on feeding pattern at
each contact with mothers and children under age 2, and regular planned review by
health practitioners.
In addition, the National Authority should review the summaries of these records, as
well as periodic surveys, to assess progress and area where programme adjustment may
be necessary.
- 4D. Monitoring and evaluation plan
The National Authority is responsible for keeping records and supporting the planning
necessary to ensure that all facilities are encouraged or mandated to follow the BFHI
criteria. In addition, this body will review all available data and ensure that analyses are
carried out, in collaboration with Health information system directorate and national
statistics offices, and the information used to improve programming and further the IYCF
goals.
Step 5:
BFHI Coordination Group coordinates facility-level assessments, re-assessments and
designation of “Baby-friendly” status.
“Baby-friendly” assessments and designations may begin as soon as the BCG, with or
without BDCs, is established by the National Authority, and after the facilities carry out
the self-assessment and consider themselves compliant with the “Ten Steps”.
Designations should be based on an assessment as per national guidelines and should be
monitored, and, where necessary, probationary periods established. Once designation is
achieved, the designation must be for a pre-set number of months or years, based on in-
country experience with duration of compliance. The date of designation, as well as the
end date of the period of designation, must be posted on the designation plaque. If this is
a new programme, it is suggested that designation not be for a period greater than 3 years.
If facilities fail to be in compliance when re-assessed, they will be allowed one

additional opportunity to achieve the necessary standards. If facilities only fail on a few
steps or Global Criteria, they can be retested just on these specific components. If the
areas in which they lack compliance are major, a full “reassessment” should be
scheduled. The second reassessment (either partial or full) will determine if the “Baby-
friendly” designation must be removed, or if a new plaque, with the new date of
obsolescence, will be granted.
Re-assessment is necessary prior to the date when designation will elapse. Records
should be kept by the National Authority of the status of every maternity facility in the
country, and every effort should be made to achieve 100% designation. [N.B. Criteria and
assessment tools have been adapted to allow for settings where there is a high incidence
of HIV- positive mothers.]
If a facility has 1) a designation that has expired, or 2) been observed/reported as having
experienced deterioration of its adherence to the Ten Steps, the BCG, or the BDC as its
agent, should arrange for a reassessment. The expiration dates should be kept on record
by the BCG/BDC and arrangements should be initiated in a timely manner for re-
assessment. Between assessments, if a health professional or other observer reports
deterioration, the facility should be notified and asked for response. If the BCG/BDC
finds the response inadequate, an interim visit can be arranged.
If a designation has expired or a facility is found to be non-compliant during the term of
its designation, the National Authority should remove any designation plaques and
remove this hospital from the list of those facilities that are designated as “Baby-
friendly” until such time as re-assessment and restoration of status occurs. A
probationary period may be granted, with a quality assessment team sent to work with
the facility if needed, and then reassessment arranged, before resorting to removal of the
plaque. These steps will depend in part on which model has been established by the
National Authority for assessment
In most case the National Authority is responsible for the formal presentation of the
designation, but may assign this role to the BCG, which is responsible for acquiring the
designation posters from the UNICEF supply catalogue and for having the designation
plaques printed in the local language. Specifications for the plaques are available on the
UNICEF intranet.
The BCG should develop a plan, to be approved by the National Authority, to ensure
designation of all public and private facilities nation-wide, and re-designation of those
facilities that have failed to maintain standards, and whose designation has been rescinded.
Five Steps in Implementing BFHI at the Country Level:

Suggested Inputs and Outputs
Step Inputs Outputs
1. Government commitment to the Global Government supported or
Establish, re-energize, or Strategy for Infant and Young Child endorsed National Authority
plan a meeting of the Feeding, including BFHI evidenced by established, with commitment
National Authority willingness to incorporate support into to developing/ strengthening
(Breastfeeding, Infant and national budget or national accrediting BFHI.
Young Child Feeding, or approach. Analysis of current status on
Nutrition Authority) to Review of existing data on breastfeeding, IYCF and BFHI completed,
establish or assess its and BFHI if already established, completed. with listing of all national
functions related to BFHI (If data are not available), rapid baseline facilities and their BFHI
survey(s) of country-level breastfeeding status.
practices, support, and status using short
questionnaire or WHO implementation
planning tool carried out and analysed.
2. Necessary meetings and functions Five-year strategic plan with
Identify - or re-establish - convened by National Authority to identify budget for the National
national BFHI goals and national goals, specific and measurable Authority and BFHI-
approaches objectives and indicators, and possible associated activities created.
expansion/integration approaches to BFHI
in the local context.
3. Most appropriate BCG option identified by A sustainable approach has
Identify, designate or the National Authority for their setting and been selected.
develop a BFHI resources based on the decisions BCG and/or procedures and
Coordination Group concerning BFHI and possible expansions processes for designation
(BCG). areas. established and approved by
The BCG plan of action in response to the National Authority and
5-year strategic plan presented to the recognized by government.
National Authority for approval and support. BCG activated.
4. Regular reports provided by BCG to the Feedback is provided by the
Ensure: National Authority. National Authority to the BCG,
1) that the BCG fulfils its Meetings/functions as necessary to review and to Government and civil
responsibility to provide, content of curricula of all health workers and society.
directly or indirectly, the auxiliary workers, such as agricultural Training and curricula are
initial or ongoing extension workers convened by National updated.
assessments of facilities, Authority. HIS records of feeding pattern
2) development of a plan for Support for curricula revision identified, with and growth for all children
pre-and in-service curricula National Authority assistance as necessary. under age 2+ are available and
revision (if needed) and analysed.
BFHI training, Coverage and analyses discussed/ensured
3) that national health through meetings of the National Authority Periodic surveys on feeding
information system with Health information system directorate patterns are conducted.
includes a record of and national statistics offices. Analyses carried out to identify
feeding status on all programme adjustments
contacts with children necessary.
under 2 years of age, and
4) Monitoring and
evaluation plan.
5: BCG instituted plan of action, including BCG form and function,
Coordinate facility-level the training of BDCs if determined including the possibility of
assessments, re- necessary to meet national goals, with subsidiary BDC, is finalised
assessments and assistance as needed from National and functioning.
designation of “Baby- Authority. Facilities, communities, etc.
friendly” status. are assessed and
designations made in
accordance with plan.
Plan reviewed regularly for
feasibility and adaptation if
needed.
National Criteria for Baby-friendly Community Designation

In order to ensure community support, as outlined in Step 10 of the BFHI, there is a
need to more actively involve the community in support of optimal IYCF. The concept
of “Baby-friendly Communities” emerged from the recognition of this need. In some
countries, there are established criteria for Baby Friendly Community Health Services.
This approach is applicable where not all of the population has ready access to facilities,
and may work best where community services fully reach all mothers and children.
In settings where the health system outreach may not be as comprehensive, a national
effort to create Baby-friendly Communities may be necessary to achieve optimal
feeding practices. The Model National Baby-friendly Community components presented
here are provided as a basis for community discussion of needs, reflecting on all
applicable Global Criteria for the BFHI (the Ten Steps, the Code, HIV and infant feeding,
and mother-friendly care). Locally developed criteria should minimally include:
1. Community political and social leadership, both male and female, committed to
making a change in support of optimal IYCF.
2. All health facilities, or local health care provision, are designated “Baby-friendly”
and actively support both early and exclusive breastfeeding (0-6 months).
3. Community access to referral site(s) with skilled support for early, exclusive and
continued breastfeeding available.
4. Support available in community for age-appropriate, frequent, and responsive
complementary feeding with continued breastfeeding. This will generally mean
that there is availability of micronutrients or animal-based foods).
5. Mother-to-mother support system, or similar, in place. (In settings with high
HIV prevalence among women of child-bearing age, extra support should be
available to HIV positive mothers).
6. No practices, distributors, shops or services that violate the International Code
(as applicable) in the community;
7. Local government or civil society convenes, creates and supports
implementation of at least one political or social normative change and/or
additional activity that actively supports mothers and families to succeed with
immediate and exclusive breastfeeding practices (e.g. time-sharing of tasks,
granting authority to transport a breastfeeding mother for referral if needed,
identification of “breastfeeding advocates/protectors” among community
leaders, breastfeeding supportive workplaces, etc.).
Details on the development of the Baby-friendly Community approach, other expansion
and mainstreaming approaches are available in Section 1.5.
Section 1.1 - Annex 1:
Suggested Questions for a Rapid Baseline Country Assessment
Where there is already an active National Authority or BFHI programme, ensure

that data are available to fully answer:
1. What is the status of BFHI?
How is assessment carried out?
What group grants the designation?
How is it funded?
Is there any potential conflict of interest in its functions?
How many and what percent of hospitals have ever been designated?
What percentage of births take place in facilities currently designated as Baby
Friendly?
How many of these have been assessed or re-assessed in the last 3-5 years and
found to be in compliance?
What percentage of facilities continues to be in compliance?
2. Is there a list of the names and locations of all maternities, hospital based or free-
standing, in the country?
3. Is there a list of the names, locations, and contact individuals of all BFH-designated
facilities, with date of initial designation and dates of re-assessments/re-
designations?
4. What are the names and addresses of trained external assessors and BFHI trainers,
as well as other national expertise, such as Certified Lactation Consultants or
Fellows of the Academy of Breastfeeding Medicine?
5. What is the current status and enforcement of law related to the International Code
of Marketing of Breast-milk Substitutes?
6. What are the current standards of practice promulgated by professional medical and
healthcare organizations?
7. What are the trends and levels of immediate postpartum breastfeeding? Exclusive
breastfeeding in the first 6 months? Continued breastfeeding at about 2 years?
8. What are the local complementary feeding practices? Have the 10 Principles of
Complementary Feeding been adopted/initiated?
9. What are the names, descriptions and contacts for all IYCF-supportive programmes
in country, including HIV/IF counselling, emergency preparedness agencies,
extension workers in the agricultural or social arenas, etc?
10. What additional related services and structures could help support IYCF?
Where there is not as yet an active BFHI programme, gather baseline information.
Suggested approach: Interview 25 key informants, selected from among knowledgeable
individuals in both public and private health sectors, non-governmental infant and
young child feeding support, or other persons familiar with hospital activities, and
request copies of any standards of practice, curricula, lists, laws or contacts mentioned.
1. Have any studies been carried out on feeding practices of infants and young
children, whether by nutrition, health, reproductive health or other interest groups?
2. Have any surveys or other data collection instruments been used to assess:
- immediate postpartum breastfeeding rates,
- six months exclusive breastfeeding rates,
- and/or
- continued breastfeeding with complementary feeding?
- Are there any trend data for any of these patterns?
3. Are there government policies or laws that pertain to infant and young child
feeding?
- For hospitals/maternities?
- For the commercial sector? Is there a national law implementing the
International Code of Marketing of Breastmilk Substitutes and subsequent
WHA resolutions?
- For the workplace?
- For emergencies?
- For HIV/AIDS?
4. What training courses or curricula exist to train:

- Health workers in the “Breastfeeding Promotion and Support in a BFHI
hospital” (20 hour course)?
- Trainers for facilitating the 20 hour course?
- Specialists in lactation support to act as referral/resource people?
- Assessors or credentialing boards?
- Health workers trained in Breastfeeding/Complementary Feeding/HIV
integrated 6 day course?
- Other? Specify.
5. Do you know of any Academic Centres involved in supporting Infant and Young
Child Feeding? (List all with contacts)
Please explain whether this is training, research, and/or support of staff to
breastfeed.
6. What Professional Societies are active in the area of Infant and Young Child
Feeding and who are the contacts? Do they have standards of practice for their
specialty?
7. What group certifies hospitals and maternities?
8. Do you know of any NGOs involved in supporting Infant and Young Child
Feeding?
(List all with contacts)
9. Do you know of any government entities involved in supporting and/or monitoring:

- Infant and Young Child Feeding related activities?
- BFHI?
- International Code of Marketing?
- Any other issue that relates to mothers or children, whether health, social, or other
sector?
10. Do you know of any data bases that are maintained regularly on any aspect of
IYCF? (List all with contacts)
11. Do you know any individuals, or rosters of individuals, with
- Experience of conducting BFHI assessments?
- Specialist training and experience dealing with unusual or difficult breastfeeding
situations?
- Training in breastfeeding support skills?
- Training in providing support for infant feeding in the context of HIV and support
for the non-breastfed infant?
- Training on Code-related issues such as development of legislation of the Code,
monitoring and enforcement
- Training in emergency settings, including relactation and therapeutic feeding?
- Experience in facilitating training in breastfeeding for health workers?
(Develop lists)
12. What resources are available to support BFHI? From what sources?
Is this support sustainable?
13. Are there additional breastfeeding support activities in other health/nutrition
/social/development programming?
14. Do you know of any government agency(ies) or individuals who are interested in
supporting IYCF?
Excerpts from recent WHO, UNICEF, or other global publications

or releases
Occasionally, those implementing BFHI in a country may need to call upon excerpts
from globally recognized sources to support their actions and plans. This section is
provided to address this need.
From UNICEF Press Release, August 2004

“UNICEF analyses on child survival show that breastfeeding could save more
children’s lives than any other single preventive health measure. Every year more
than 10 million children die from mainly preventable causes, including diarrhoea,
pneumonia, measles and malaria. If every baby were exclusively breastfed from
birth to six months, an estimated 3500 children’s lives could be saved each day.
“Simply put, if a child dies a preventable death, it’s from neglect. The world has the
power, money and tools to keep that child alive” said Carol Bellamy, (former)
Executive Director of UNICEF. “This is especially true of breastfeeding, and
children the world over have the absolute need and right to this key to their survival.”
To achieve this, Bellamy notes, every mother who chooses to exclusively
breastfeed for 6 months needs social and health care support from their
governments, communities and families.”
From UNICEF Executive Director Ann M Veneman for World Breastfeeding

Week, 2005:
If we are to fulfill the promise of the Millennium Declaration and the Millennium
Development Goals, we must renew our attention to those interventions that are
effective, affordable and have significant impact. Improvements in breastfeeding
and complementary feeding are essential for success in child survival, in reducing
hunger, and to ensure that children develop in a manner that they may best benefit
from education and opportunity.
UNICEF applauds the commitment of all of those involved in support of child
survival through optimal infant and young child feeding in the celebration of this
year's World Breastfeeding Week.
From “Investing in Development: A Practical Plan to Achieve the Millennium

Development Goals.” 2005, Millennium Project, New York, p. 26 “The Quick Wins
needed to be embedded in the longer term investment policy framework of the
MDG-based poverty reduction strategy”
“[In the design of] community nutrition programs that support breastfeeding,
provide access to locally produced complementary foods, and, where needed,
provide micronutrient…supplementation for pregnant and lactating women…”
From World Health Assembly 2004:

From: Global strategy on diet, physical activity and health A57/9 and WHA 57/17:
11. Maternal health and nutrition before and during pregnancy, and early infant
nutrition may be important in the prevention of non-communicable diseases
throughout the life course. Exclusive breastfeeding for six months and appropriate
complementary feeding contribute to optimal physical growth and mental
development.
From: Family and health in the context of the tenth anniversary of the
International Year of the Family A57/12
6. Almost 50% of all infant deaths in developing countries occur in the first 28 days
after birth. As most infants in these countries are born at home, improvements in
facility-based services will address only part of the problem and must be
complemented by interventions in the home and community. A few simple
interventions, such as aiding birth with skilled attendants, keeping the neonate
warm, initiating breastfeeding early and recognizing and treating common
infections, will greatly increase chances of neonatal survival.
From A57/18 Biennial Updates
E. INFANT AND YOUNG CHILD NUTRITION: BIENNIAL PROGRESS
REPORT 48.
Despite overall improvements in exclusive breastfeeding …, practices fall far short
of WHO’s global public health recommendation: exclusive breastfeeding for six
months followed by safe and appropriate complementary feeding with continued
breastfeeding for up to two years of age or beyond (resolution WHA54.2).
FIFTY-SEVENTH WORLD HEALTH ASSEMBLY WHA57.14, Agenda item
12.1 22 May 2004
Scaling up treatment and care within a coordinated and comprehensive response to
HIV/AIDS
2. URGES Member States, as a matter of priority: (3) to pursue policies and
practices that promote:
(h) integration of nutrition into a comprehensive response to HIV/AIDS;
(i) promotion of breastfeeding in the light of the United Nations Framework for
Priority Action on HIV and Infant Feeding and the new WHO/UNICEF Guidelines
for Policy-Makers and Health-Care Managers;

The contribution of Breastfeeding and Complementary Feeding
to achieving the Millennium Development Goals 4
Goal Number and Targets Contribution of Infant and Young Child feeding5
Breastfeeding significantly reduces early childhood

feeding costs, and exclusive breastfeeding halves the
Eradicate extreme poverty
cost of breastfeeding6.Exclusive breastfeeding and
and hunger
continued breastfeeding for two years is associated
Halve, between 1990 and
with reduction in underweight7 and is an excellent
1 2015, the proportion of
source of high quality calories for energy. By reducing
people whose income is
fertility, exclusive breastfeeding reduces reproductive
less than $1 a day, and who
stress. Breastfeeding provides breastmilk, serving as
suffer from hunger.
low-cost, high quality, locally produced food and
sustainable food security for the child.
Breastfeeding and adequate complementary feeding

are prerequisites for readiness to learn8.
Achieve universal
Breastfeeding and quality complementary foods
primary education
significantly contribute to cognitive development and
Ensure that by 2015,
capacity. In addition to the balance of long chain fatty
children everywhere,
2 acids in breastmilk, which support neurological
boys and girls alike, will
development, initial exclusive breastfeeding and
be able to complete a full
complementary feeding address micronutrient and
course of primary
iron deficiency needs and, hence, support appropriate
education.
neurological development and enhance later school
performance.
Breastfeeding is the great equalizer, giving every child

a fair start on life. Most differences in growth between
Promote gender
sexes begin as complementary foods are added into the
equality and empower
diet, and gender preference begins to act on feeding
women
decisions. Breastfeeding also empowers women:
Eliminate gender disparity
- increased birth spacing secondary to breastfeeding
3 in primary and secondary
helps prevents maternal depletion from short birth
education, preferably by
intervals,
2005 and in all levels of
- only women can provide it, enhancing women’s
education no later than
capacity to feed children,
2015.
- increases focus on need for women’s nutrition to be
considered.
4
Developed by the UN Standing Committee on Nutrition Working Group on Breastfeeding and Complementary Feeding, 2003/4
5
Early and Exclusive Breastfeeding, continued breastfeeding with complementary feeding and related maternal nutrition
6
Bhatnagar, S, Jain, N. P. & Tiwari, V. K. Cost of infant feeding in exclusive and partially breastfed infants. Indian Pediatr. 33, 655-658 (1996).
7
Dewey, K. G. Cross-cultural patterns of growth and nutritional status of breast-fed infants. Am. J. Clin. Nutr. 67, 10-7 (1998).
8
Anderson, J. W., Johnstone, B. M. & Remley, D. T. Breast-feeding and cognitive development: a meta-analysis. Am. J. Clin. Nutr. 70, 525-35 (1990)
By reducing infectious disease incidence and severity,

breastfeeding could readily reduce child mortality by
about 13%, and improved complementary feeding
would reduce child mortality by about 6%.9 In addition,
Reduce child mortality about 50-60% of under-5 mortality is caused by mal-
Reduce by two-thirds, nutrition due to inadequate complementary foods and
4 between 1990 and 2015, feeding following on poor breastfeeding practices10
the under-five mortality and, also, to low birth weight. The impact is increased
rate. in unhygienic settings. The micronutrient content of
breastmilk, especially during exclusive breastfeeding,
and from complementary feeding can provide essential
micronutrients in adequate quantities, as well as
necessary levels of protein and carbohydrates.
The activities called for in the Global Strategy include

increased attention to support for the mother's nutritional
and social needs. In addition, breastfeeding is
associated with decreased maternal postpartum blood
loss, breast cancer, ovarian cancer, and endometrial
Improve maternal health cancer, as well as the probability of decreased bone loss
Reduce by three-quarters, post-menopause. Breastfeeding also contributes to the
5
between 1990 and 2015, duration of birth intervals, reducing maternal risks of
the maternal mortality ratio. pregnancy too close together, including lessening risk of
maternal nutritional depletion from repeated, closely-
spaced pregnancies. Breastfeeding promotes return of
the mother’s body to pre-pregnancy status, including
more rapid involution of the uterus and postpartum
weight loss (obesity prevention).
Based on extrapolation from the published literature

Combat HIV/AIDS, malaria
on the impact of exclusive breastfeeding on MTCT,
and other diseases
exclusive breastfeeding in a population of untested
6 Have halted by 2015 and
breastfeeding HIV-infected population could be
begun to reverse the spread
associated with a significant and measurable
of HIV/AIDS.
reduction in MTCT.
Breastfeeding is associated with decreased milk industry

waste, pharmaceutical waste, plastics and aluminium tin
Ensure environmental waste, and decreased use of firewood/fossil fuels for
7
sustainability alternative feeding preparation,11 less CO2 emission as a
result of fossil fuels, and less emissions from transport
vehicles as breastmilk is locally produced.
The Global Strategy for Infant and Young Child

Feeding fosters multi-sectoral collaboration, and can
Develop a global
build upon the extant partnerships for support of
8 partnership for
development through breastfeeding and complementary
development
feeding. In terms of future economic productivity,
optimal infant feeding has major implications.
9
Jones, G. et al. How many child deaths can we prevent this year? Lancet 362, 65-71 (2003).
10
Pelletier D.Frongillo, E. Changes in child survival are strongly associated with changes in malnutrition in
developing countries. J. Nutr. 133, 107-119 (2003)
11
Labbok M. Breastfeeding as a women's issue: conclusions and consensus, complementary concerns, and next
actions. IJGO 1994; 47(Suppl):S55-S61
21
SECTION 1.2:
HOSPITAL LEVEL IMPLEMENTATION
Breastfeeding Rates
The Baby-friendly Hospital Initiative (BFHI) seeks to provide mothers and babies with
a good start for breastfeeding, increasing the likelihood that babies will be breastfed
exclusively for the first six months and then given appropriate complementary foods
while breastfeeding continues for two years or beyond.
For purposes of assessing a maternity facility, the number of women breastfeeding
exclusively from birth to discharge may serve as an approximate indicator of whether
protection, promotion, and support for breastfeeding are adequate in that facility. The
maternity facility’s annual statistics should indicate that at least 75% of the mothers
who delivered in the past year are either exclusively breastfeeding or exclusively
feeding their babies breast milk from birth to discharge or, if not, that it is because of
acceptable medical reasons or fully informed choices. (Mothers who are HIV positive
and have made an informed decision to replacement feed are considered as having made
an “informed choice” and can be counted as meeting the criterion.) If fewer than 75% of
women who deliver in a facility are breastfeeding exclusively from birth to discharge, the
managers and staff may wish to study the results from the Self Appraisal, consider the
Global Criteria carefully, and work, through the Triple A process of assessment, analysis,
and action, to increase their exclusive breastfeeding rates. Once the 75% exclusive
breastfeeding goal has been achieved, an external assessment visit should be arranged.
The BFHI cannot guarantee that women who start out breastfeeding exclusively will
continue to do so for the recommended 6 months. However, research studies have
shown that women whose babies have received early supplemental feeding in hospital
are extremely unlikely to rely upon exclusive breastfeeding after that. By establishing a
pattern of exclusive breastfeeding during the maternity stay, hospitals are taking an
essential step toward longer durations of exclusive breastfeeding after discharge.
If hospital staff believes that antenatal care provided elsewhere contributes to rates of
less than 75% breastfeeding after the birth, or that community practices need to be more
supportive of breastfeeding, they may consider how to work with the antenatal
caregivers to improve antenatal education on breastfeeding and with breastfeeding
advocates to improve community practices. (See Section 1.5 for a discussion of
strategies for fostering Baby-friendly Communities.)
Supplies of Breastmilk Substitutes
Research has provided evidence that clearly shows that breastmilk substitute marketing
practices influence health workers’ and mothers’ behaviours related to infant feeding.
Marketing practices prohibited by The International Code of Marketing of Breast-milk
Substitutes (the Code) have been shown to be harmful to infants, increasing the
likelihood that they will be given formula and other items under the scope of The Code
and decreasing optimal feeding practices. The 1991 UNICEF Executive Board called
for the ending of free and low-cost supplies of formula to all hospitals and maternity
wards by the end of 1992. Compliance with The Code is required for health facilities to
achieve Baby-friendly status.
Section 1.2: Hospital Level Implementation 22
Questions have been added to the Self-Appraisal Tool that will help the national BFHI
coordination groups and maternity facilities determine how well their maternity services
are complying with The Code and subsequent WHA resolutions and what actions are
needed to achieve full compliance.
HIV and Infant Feeding

The increasing prevalence of HIV among women of childbearing age in many countries has
made it important to give guidance on how to offer appropriate information and support for
women related to HIV within the BFHI. Thus, as mentioned earlier, components on HIV
and infant feeding have been added to the 20-hour Course and to the Global Criteria and
assessment tools.
The course material aims to raise the awareness of participants as to why BFHI continues
to be important in areas of high HIV prevalence and ways to assist mothers who are HIV-
positive as part of regular care in the health facility. This 20-hour course does not train
participants to counsel women who are HIV-positive on infant feeding decisions.
Another course and counselling aids are available from WHO for that specialized
training and counselling.
It is recommended that the BFHI coordination groups in each country work with other
relevant national decision-makers to determine whether the HIV components of the
assessment will be required and whether this requirement will be for all facilities or only
those meeting specified criteria. The decision should be based on the prevalence of HIV
among pregnant women and mothers and, therefore, the need for information and support
on this issue. If this information is not available, surveys may be necessary to determine
what percentages of pregnant women and mothers using the antenatal and delivery
services in maternity facilities are HIV positive. It is suggested that if a maternity facility
has a prevalence of more than 20% HIV positive clients, and/or has a PMTCT12
program, this component of the assessment should be required. If prevalence is over
10%, the use of this component is strongly advised. National decision-makers in
countries with high HIV prevalence may decide to include additional HIV-related
criteria and questions, depending on their needs.
The Global Criteria, Self-Appraisal Tool and Hospital External Assessment Tool all
have HIV-related items added in such a way that they can be included or not, depending
on the need. The HIV and Infant Feeding criteria are listed separately in the Global
Criteria. The questions related to HIV in both the Self-Appraisal and the various
interviews in the Assessment Tool are either presented in separate sections or at the end
of the respective interviews. There is a separate Summary Sheet in the Assessment Tool
to display the HIV-related results.
12 Prevention of mother-to-child-transmission (of HIV/AIDS).
Mother-friendly Care
Optional new Global Criteria and questions have been added to insure that practices are
in place for mother-friendly labour and delivery. These practices are important, in their
own right, for the physical and psychological health of the mothers themselves, and also
have been shown to enhance their infants’ start in life, including breastfeeding. Many
countries have explored options for including mother-friendly criteria within the
Initiative, in some cases re-terming their national initiatives as “mother and baby
friendly”. Other countries have adopted full “mother-friendly” initiatives. New self-
appraisal and assessment questions on this topic offer a way for countries that have not
done so already to add a component focused on the key “mother-friendly” criteria
needed for an optimal “continuum of care” for both mother and child from the antenatal
to postpartum period.13
The Baby-friendly Hospital Designation Process

The BFHI is initiated at national level, with government, UNICEF, WHO, breastfeeding
groups, and others interested parties as catalysts. The Global Criteria and Self-
Appraisal Tool are available to all who are interested in accessing it on the UNICEF
website. UNICEF and WHO will encourage the national authorities and BFHI
coordination groups to access it and encourage health facilities to join or continue to
participate in the Initiative. For details on country level implementation, please read
Section 1.1 of this document.
At the facility level the assessment and designation process includes a number of steps,
with facilities following differing paths, depending on the outcomes at various stages of
the process. Once a facility has used the Self-Appraisal Tool to conduct a “self
assessment” of whether it meets Baby Friendly standards and has studied the Global
Criteria to determine whether an external assessment is likely to give the same results,
it will decide whether or not it is ready for external assessment.
If the facility determines that it is ready for external assessment in some countries the
next step would be an optional or required pre-assessment visit during which an outside
consultant explores the readiness of the hospital for a full assessment, using the Self-
Appraisal Tool and Global Criteria. This could be done through an on site visit or by
means of an extensive telephone interview/survey, if travel costs are prohibitive. This
can be a quite useful intermediate step, as many hospitals overrate their compliance with
the Global Criteria and this type of visit, followed by working on any further
improvements needed, can save a lot of time, money, and anguish both for the hospital
and the national BFHI coordination group.
If a facility has used the Self-Appraisal Tool, studied the Global Criteria, and received
feedback during a pre-assessment visit, if scheduled, and determined that it does not yet
meet the BFHI standards and recognizes its need for improvement, it should analyse its
deficiencies and develop plans to address them. This may include scheduling the 20-
hour Course (presented in Section 3 of these BFHI materials) for its maternity staff, if
this training has not been given or was conducted very long ago.
13
See the website for the Coalition for Improving Maternity Services (CIMS) http://www.motherfriendly.org/MFCI/
for a description of The Mother- Friendly Childbirth Initiative.
The facility may also request a Certificate of Commitment while it is working to become
Baby-friendly, if the BFHI coordination group supplies this for facilities at this stage of
the process. When it is ready, the facility should then request an external assessment,
following the process described in the paragraph above.
The next step, as mentioned above, would be for a facility to request or invite an
external assessment. The BFHI coordination group may review the Self Appraisal
results, any supporting documents that it requires, and the results from a pre-assessment
visit, if one has been made, to help determine if the facility is ready. The external
assessment will determine whether the facility meets the Global Criteria for a Baby-
friendly Hospital. If so, the BFHI coordination group should award the facility the
Global BFH Award and Plaque for a specified period.
If the facility, on the other hand, does not meet the Global Criteria, it would be awarded
a Certificate of Commitment to becoming Baby-friendly and would be encouraged or
supported to further analyse problem areas and take whatever actions are needed to
comply, then inviting another assessment. Whether this second assessment would be a
full one, or only partial, focusing on those criteria on which the facility did not
originally comply, would depend on the decision made by the assessors and BFHI
coordination group at the time of the original assessment.
If the national BFHI coordination group finds that hospitals that have been assessed as
failing at times do not agree with the conclusions reached by the assessors, it might
consider setting up an appeal process, when necessary, with a review of results by
panels of assessors not involved in the original assessments.
Reassessments should be scheduled for Baby-friendly hospitals, after the specified
period for the Award. If the facility passes the reassessment, it should be given a
renewal. If not, it needs to work to address any identified problems and then apply again
for reassessment.
This process is illustrated in graphic form in the flow chart on the following page.
THE BABY-FRIENDLY HOSPITAL DESIGNATION PROCESS
Facility appraises its own practices, using the Self-Appraisal Tool and studying the Global Criteria.
Either: Meets high standards, as indicated by the self- Or: Does not meet standards but
appraisal, and has 75% exclusively breastfeeding from recognizes need for improvements.
birth to discharge.1
Facility requests external assessment. (If available, the Facility studies the Global Criteria,
first step is a “pre-assessment” by a local consultant/ analyses deficiencies and develops plan
assessor to help determine if the facility is ready, and to of action to become baby friendly.
assist with any final improvements needed.) Requests Certificate of Commitment*
and any support needed.
Facility invites external assessors to conduct an

assessment using the Hospital External Assessment Tool. Facility implements plan of action,
including further staff training, if
needed, until baby-friendly practices
Either: Meets the Or: Does not meet the become routine.
Global Criteria for a Global Criteria for a (Then requests external assessment)
baby-friendly hospital. baby-friendly hospital.
Notes:
1. If a mother is not exclusively
BFHI coordination BFHI coordination group breastfeeding but it is verified that it
group awards the may provide a Certificate is for an acceptable medical reason or
hospital the WHO/ of Commitment3 to for fully informed choice, she can be
UNICEF Global BFH become Baby-friendly, or counted as meeting the criterion.
Award and Plaque.2 alternative notification.
2. An external assessment team does not
designate a hospital as Baby-friendly.
The national BFHI coordination
Facility monitors its Facility analyses problem
group makes the final decision, after
practices and works to areas and schedules further
checking that the assessment results
maintain standards.4 action to become Baby-
are accurate.
friendly. Requests support
needed. 3. Some countries include the Certificate
After three years (or a of Commitment as an interim step
period decided by towards designation as baby-friendly.
BFHI) the BFHI Facility implements plan In these settings, if a facility does not
coordination group of action until baby- meet standards after self-appraisal or
arranges for friendly practices become after an external assessment, they can
reassessment, using routine, then invites request a certificate. However, it is
the Assessment Tool or external assessor(s). the responsibility of the national
a reassessment tool. authority or BFHI coordination group
to set the standards for such
certificates. Some countries provide a
Facility passes Facility fails certificate of participation for
reassessment and reassessment and does facilities at the early stage if facility
receives an extension not receive renewal BFH staff has conducted self-appraisal and
of the BFH award. award. needs to make further improvements
before requesting an external
assessment.
4. A facility that attains the BF status
may consider immediate action to
expand the Global Criteria based on
needs of the community.
26
SECTION 1.3
THE GLOBAL CRITERIA FOR THE BFHI
Criteria for the 10 Steps, the Code, and optional components

The Global Criteria for the Baby-friendly Hospital Initiative serves as the standard for
measuring adherence to each of the Ten Steps for Successful Breastfeeding and the
International Code of Marketing of Breast-milk Substitutes. The criteria listed below for
each of the Ten Steps and the Code is the minimum global criteria for baby-friendly
designation. Additional criteria are provided for “HIV and Infant Feeding” and
”Mother-friendly care”, with the recommendation that relevant decision-makers in each
country decide whether these criteria should be required, depending on the prevalence
of HIV among women using the maternity facilities and whether it seems appropriate to
include criteria related to mother-friendly labour and childbirth.
The BFHI Self-Appraisal Tool, presented in Section 4 of this series, gives maternity
facilities a tool for making a preliminary assessment of whether they are fully
implementing the Ten Steps, adhering to the International Code of Marketing, and
meeting criteria related to HIV and infant feeding and mother-friendly care. The Global
Criteria actually describe how “baby-friendliness” will be judged during the external
assessment, and thus can be very useful for maternity staff to study as they work to get
ready for assessment. The Global Criteria are listed both here and after the respective
sections of the Self Appraisal Tool, for easy reference during self-appraisal.
It is important that the hospital consider adding the collection of statistics on feeding
and implementation of the Ten Steps into its maternity record-keeping system, if it has not
done so already. It is best if this data collection process be integrated into whatever
information gathering system is already in place. If the hospital needs guidance on how
to gather this data and possible forms to use, responsible staff can refer to the sample
data-gathering tools available in Section 4.2: Guidelines and Tools for Monitoring BFHI.
STEP 1. Have a written breastfeeding policy that is routinely communicated to

all health care staff.
Global Criteria - Step One

The health facility has a written breastfeeding or infant feeding policy that addresses all
10 Steps and protects breastfeeding by adhering to the International Code of Marketing of
Breast-milk Substitutes. It also requires that HIV-positive mothers receive counselling on
infant feeding and guidance on selecting options likely to be suitable for their situations.
The policy is available so that all staff who takes care of mothers and babies can refer to
it. Summaries of the policy covering, at minimum, the Ten Steps, the Code and
subsequent WHA Resolutions, and support for HIV-positive mothers, are visibly posted
in all areas of the health care facility which serve pregnant women, mothers, infants,
and/or children. These areas include the antenatal care, labour and delivery areas,
maternity wards and rooms, all infant care areas, including well baby observation areas (if
there are any), and any infant special care units. The summaries are displayed in the
language(s) and written with wording most commonly understood by mothers and staff.
Section 1.3: Global Criteria 27
STEP 2. Train all health care staff in skills necessary to implement the policy.
Global Criteria - Step Two

The head of maternity services reports that all health care staff members who have any
contact with pregnant women, mothers, and/or infants, have received orientation on the
breastfeeding/infant feeding policy. The orientation that is provided is sufficient.
A copy of the curricula or course session outlines for training in breastfeeding promotion
and support for various types of staff is available for review, and a training schedule for
new employees is available.
Documentation of training indicates that 80% or more of the clinical staff members who
have contact with mothers and/or infants and have been on the staff 6 months or more
have received training, either at the hospital or prior to arrival that covers all 10 Steps,
and the Code and subsequent WHA resolutions. It is likely that at least 20 hours of
targeted training will be needed to develop the knowledge and skills necessary to
adequately support mothers. 3 hours of supervised clinical experience are required.
Documentation of training also indicates that non-clinical staff members have received
training that is adequate, given their roles, to provide them with the skills and knowledge
needed to support mothers in successfully feeding their infants.
Training on how to provide support for non-breastfeeding mothers is also provided to
staff. A copy of the course session outlines for training on supporting non-breastfeeding
mothers is also available for review. The training covers key topics such as:
the risks and benefits of various feeding options,
helping the mother choose what is acceptable, feasible, affordable, sustainable and
safe (AFASS) in her circumstances,
the safe and hygienic preparation, feeding and storage of breast-milk substitutes,
how to teach the preparation of various feeding options, and
how to minimize the likelihood that breastfeeding mothers will be influenced to use
formula.
The type and percentage of staff receiving this training is adequate, given the facility’s needs.
Out of the randomly selected clinical staff members*:
at least 80% confirm that they have received the described training or, if they have
been working in the maternity services less than 6 months, have, at minimum,
received orientation on the policy and their roles in implementing it
at least 80% are able to answer 4 out of 5 questions on breastfeeding support and
promotion correctly
at least 80% can describe two issues that should be discussed with a pregnant woman if
she indicates that she is considering giving her baby something other than breastmilk
Out of the randomly selected non-clinical staff members**:
at least 70% confirm that they have received orientation and/or training concerning
breastfeeding since they started working at the facility
at least 70% are able to describe at least one reason why breastfeeding is important,
at least 70% are able to mention one possible practice in maternity services that
would support breastfeeding.
at least 70% are able to mention at least one thing they can do to support women so
they can feed their babies well.
* These include staff members providing clinical care for pregnant women, mothers and their babies.
** These include staff members providing non-clinical care for pregnant women, mother and their
babies or having contact with them in some aspect of their work.
STEP 3. Inform all pregnant women about the benefits and management of
breastfeeding.
Global Criteria - Step Three

If the hospital has an affiliated antenatal clinic, the head of maternity or antenatal
services reports that at least 80% of the pregnant women who are provided antenatal
care receive information about breastfeeding.
A written description of the minimum content of the antenatal education is available.
The antenatal discussion covers the importance of breastfeeding, the importance early
skin-to-skin contact, early initiation of breastfeeding, rooming-in on a 24 hour basis,
feeding on demand or baby-led feeding, frequent feeding to help assure enough milk,
good positioning and attachment, exclusive breastfeeding for the first 6 months, and the
fact that breastfeeding continues to be important after 6 months when other foods are
given.
Out of the randomly selected pregnant women in their third trimester who have come for
at least two antenatal visits:
at least 70% confirm that a staff member has talked with them or offered a group talk
that includes information on breastfeeding
at least 70% are able to adequately describe what was discussed about two of the
following topics: importance of skin-to-skin contact, rooming-in, and risks of
supplements while breastfeeding in the first 6 months.
STEP 4. Help mothers initiate breastfeeding within a half-hour of birth.

This Step is now interpreted as:
Place babies in skin-to-skin contact with their mothers immediately
following birth for at least an hour and encourage mothers to recognize
when their babies are ready to breastfeed, offering help if needed.
Global Criteria - Step Four

Out of the randomly selected mothers with vaginal births or caesarean sections without
general anaesthesia in the maternity wards:
at least 80% confirm that their babies were placed in skin-to-skin contact with
them immediately or within five minutes after birth and that this contact continued
for at least an hour, unless there were medically justifiable reasons for delayed
contact.
at least 80% also confirm that they were encouraged to look for signs for when their
babies were ready to breastfeed during this first period of contact and offered help, if
needed.
(The baby should not be forced to breastfeed but, rather, supported to do so when
ready.)
(Note: Mothers may have difficulty estimating time immediately following birth. If time and
length of skin-to-skin contact following birth is listed in the mothers’ charts, this can be used as
a cross-check.)
If any of the randomly selected mothers have had caesarean deliveries with general
anaesthesia, at least 50% should report that their babies were placed in skin-to-skin
contact with them as soon as the mothers were responsive and alert, with the same
procedures followed.
At least 80% of the randomly selected mothers with babies in special care report that
they have had a chance to hold their babies skin-to-skin or, if not, the staff could
provide justifiable reasons why they could not.
Observations of vaginal deliveries, if necessary to confirm adherence to Step 4, show
that in at least 75% of the cases babies are placed with their mothers hold skin-to-skin
within five minutes after birth for at least 60 minutes, and that the mothers are shown
how to recognize the signs that their babies are ready to breastfeed and offered help, or
there are justified reasons for not following these procedures.
STEP 5. Show mothers how to breastfeed and how to maintain lactation, even if
they should be separated from their infants
Global Criteria - Step Five

The head of maternity services reports that mothers who have never breastfed or who
have previously encountered problems with breastfeeding receive special attention and
support both in the antenatal and postpartum periods.
Observations of staff demonstrating how to safely prepare and feed breast-milk
substitutes confirm that in 75% of the cases, the demonstrations were accurate and
complete, and the mothers were asked to give “return demonstrations”.
Out of the randomly selected clinical staff members:
at least 80% report that they teach mothers how to position and attach their babies for
breastfeeding and are able to describe or demonstrate correct techniques for both, or
can describe to whom to refer mothers for this advice.
at least 80% report that they teach mothers how to hand expression and can describe
or demonstrate an acceptable technique for this, or can describe to whom to refer
mothers for this advice.
at least 80% can describe how non-breastfeeding mothers can be assisted to safely
prepare their feeds, or to whom they can be referred for this advice.
Out of the randomly selected mothers (including caesarean):
at least 80% of those who are breastfeeding report that nursing staff offered further
assistance with breastfeeding the next time they fed their babies or within six hours
of birth (or of when they were able to respond).
at least 80% of those who are breastfeeding are able to demonstrate or describe
correct positioning, attachment and suckling
at least 80% of those who are breastfeeding report that they were shown how to express
their milk by hand or given written information and told where they could get help if
needed
at least 80% of the mothers who have decided not to breastfeed report that they have
been offered help in preparing and giving their babies feeds, can describe the advice
they were given, and have been asked to prepare feeds themselves, after being
shown how.
Out of the randomly selected mothers with babies in special care:
at least 80% of those who are breastfeeding or intending to do so report that they
have been offered help to start their breastmilk coming and to keep up the supply
within 6 hours of their babies’ births
at least 80% of those breastfeeding or intending to do so report that they have been
shown how to express their breastmilk by hand
at least 80% of those breastfeeding or intending to do so can adequately describe and
demonstrate how they were shown to express their breastmilk by hand
at least 80% of those breastfeeding or intending to do so report that they have been told
they need to breastfeed or express their milk 6 times or more every 24 hours to keep up
their supply.
STEP 6. Give newborn infants no food or drink other than breastmilk, unless
medically indicated.
Global Criteria - Step Six

Hospital data indicate that at least 75% of the full-term babies delivered in the last year
have been exclusively breastfed or exclusively fed expressed breast milk from birth to
discharge, or, if not, that there were documented medical reasons or fully informed
choices.
Review of all clinical protocols or standards related to breastfeeding and infant feeding
used by the maternity services indicates that they are in line with BFHI standards and
current evidence-based guidelines.
No materials that recommend feeding breast milk substitutes, scheduled feeds or other
inappropriate practices are distributed to mothers.
The hospital has an adequate facility/space and the necessary equipment for giving
demonstrations of how to prepare formula and other feeding options away from
breastfeeding mothers.
Observations in the postpartum wards/rooms and any well baby observation areas show
that at least 80% of the babies are being fed only breastmilk or there are acceptable
medical reasons or informed choices for receiving something else.
At least 80% of the randomly selected clinical staff members can describe two types of
information that should be discussed with mothers who indicate they are considering
feeding breast milk substitutes
At least 80% of the randomly selected mothers report that their babies had received only
breast milk or, if they had received anything else, it was either for acceptable medical
reasons, described by the staff, or as a result of fully informed choices.
At least 80 % of the randomly selected mothers who have decided not to breastfeed
report that the staff discussed with them the various feeding options and helped them to
decide what was suitable in their situations.
At least 80% of the randomly selected mothers with babies in special care who have decided
not to breastfeed report that staff has talked with them about risks and benefits of various
feeding options.
STEP 7. Practice rooming-in - allow mothers and infants to remain together –

24 hours a day
Global Criteria - Step Seven

Observations in the postpartum wards and any well-baby observation areas and
discussions with mothers and staff confirm that at least 80% of the mothers and babies
are rooming-in or, if not, have justifiable reasons for not being together.
At least 80% of the randomly selected mothers report that their babies have stayed with
them in their rooms/beds since they were born, or, if not, there were justifiable reasons.
STEP 8. Encourage breastfeeding on demand.
Global Criteria - Step Eight

Out of the randomly selected mothers:
at least 80% report that they have been told how to recognize when their babies are
hungry and can describe at least two feeding cues.
at least 80% report that they have been advised to feed their babies as often and for
as long as the babies want or something similar.
STEP 9. Give no artificial teats or pacifiers (also called dummies or soothers)

to breastfeeding infants.
Global Criteria - Step Nine

Observations in the postpartum wards/rooms and any well baby observation areas
indicate that at least 80% of the breastfeeding babies observed are not using bottles or
teats or, if they are, their mothers have been informed of the risks.
At least 80% of the randomly selected breastfeeding mothers report that, to the best of
their knowledge, their infants have not been fed using bottles with artificial teats
(nipples).
At least 80% of the randomly selected mothers report that, to the best of their
knowledge, their infants have not sucked on pacifiers.
STEP 10. Foster the establishment of breastfeeding support groups and

refer mothers to them on discharge from the hospital or clinic.
Global Criteria - Step Ten

The head/director of maternity services reports that:
mothers are given information on where they can get support if they need help with
feeding their babies after returning home, and the head/director can also mention at
least one source of information
the facility fosters the establishment of and/or coordinates with mother support
groups and other community services that provide breastfeeding/infant feeding
support to mothers, and this same staff member can describe at least one way this
is done.
the staff encourages mothers and their babies to be seen soon after discharge
(preferably 2-4 days after birth and again the second week) at the facility or in the
community by a skilled breastfeeding support person who can assess feeding and
give any support needed and can describe an appropriate referral system and
adequate timing for the visits.
A review of documents indicates that printed information is distributed to mothers
before discharge, if appropriate, on how and where mothers can find help on feeding
their infants after returning home and includes information on at least one type of help
available.
Out of the randomly selected mothers at least 80% report that they have been given
information on how to get help from the facility or how to contact support groups, peer
counsellors or other community health services if they have questions about feeding
their babies after return home and can describe at least one type of help that is
available.
Compliance with the International Code of Marketing of Breast-milk Substitutes
Global Criteria – Code compliance

No employees of manufacturers or distributors of breast milk substitutes, bottles,
teats or pacifiers have any direct or indirect contact with pregnant women or
mothers
The hospital does not receive free gifts, non-scientific literature, materials or
equipment, money, or support for in-service education or events from
manufacturers or distributors of breast milk substitutes, bottles, teats or pacifiers
No pregnant women, mothers or their families are given marketing materials or
samples or gift packs by the facility that include breast milk substitutes,
bottles/teats, pacifiers, other infant feeding equipment or coupons.
A review of records and receipts indicates that any breast milk substitutes, including
special formulas and other supplies, are purchased by the health care facility for the
wholesale price or more.
Observations in the antenatal and maternity services and other areas where nutritionists
and dieticians work indicate that no materials that promote breast milk substitutes,
bottles, teats or dummies, or other designated products as per national laws, are displayed
or distributed to mothers, pregnant women, or staff.
Infant formula cans and prepared bottles are kept out of view.
At least 80% of the randomly selected clinical staff members can give two reasons why
it is important not to give free samples from formula companies to mothers.
HIV and infant feeding (optional)

Note: The national BFHI coordination group and/or other appropriate national decision-makers
will determine whether or not maternity services should be assessed on whether they provide support
related to HIV and infant feeding.
Global Criteria – HIV and infant feeding

the hospital has policies and procedures that seem adequate concerning providing or
referring pregnant women for testing and counselling for HIV, counselling women
concerning PMTCT of HIV, providing individual, private counselling for pregnant
women and mothers who are HIV positive on infant feeding options, and insuring
confidentiality.
mothers who are HIV positive or concerned that they are at risk are referred to
community support services for HIV testing and infant feeding counselling, if they
exist.
A review of the infant feeding policy indicates that it requires that HIV-positive
mothers receive counselling, including information about the risks and benefits of
various infant feeding options and specific guidance in selecting the options for their
situations, supporting them in their choices.
continued on next page
Global Criteria – HIV and infant feeding (continued from previous

page)
A review of the curriculum on HIV and infant feeding and training records indicates
that training is provided for appropriate and is sufficient, given the percentage of HIV
positive women and the staff needed to provide support for pregnant women and
mothers related to HIV and infant feeding. The training covers basic facts on:
basic facts of the risks of HIV transmission during pregnancy, labour and delivery
and breastfeeding and its prevention
importance of testing and counselling for HIV
local availability of feeding options
facilities/provision for counselling HIV positive women on advantages and
disadvantages of different feeding options; assisting them in formula feeding
(Note: may involve referrals to infant feeding counsellors)
how to assist HIV positive mothers who have decided to breastfeed; including how
to transition to replacement feeds at the appropriate time
the dangers of mixed feeding
how to minimize the likelihood that a mother whose status is unknown or HIV
negative will be influenced to replacement feed
A review of the antenatal information indicates that it covers the important topics on
this issue. (These include the routes by which HIV-infected women can pass the
infection to their infants, the approximate proportion of infants that will (and will not)
be infected by breastfeeding; the importance of counselling and testing for HIV and
where to get it; and the importance of HIV positive women making informed infant
feeding choices and where they can get the needed counselling).
A review of documents indicates that printed material is available, if appropriate, on
how to implement various feeding options and is distributed to or discussed with HIV
positive mothers before discharge. It includes information on how to exclusively
replacement feed, how to exclusively breastfeed, how to stop breastfeeding when
appropriate, and the dangers of mixed feeding.
at least 80% can describe at least one measure that can be taken to maintain
confidentiality and privacy of HIV positive pregnant women and mothers
at least 80% are able to mention at least two policies or procedures that help prevent
transmission of HIV from an HIV positive mother to her infant during feeding
within the first six months
at least 80% are able to describe two issues that should be discussed when
counselling an HIV positive mother who is deciding how to feed her baby
Out of the randomly selected pregnant women who are in their third trimester and have
had at least two antenatal visits or are in the antenatal in-patient unit:
at least 70% report that a staff member has talked with them or given a talk about
HIV/AIDS and pregnancy
at least 70% report that the staff has told them that a woman who is HIV-positive
can pass the HIV infection to her baby.
at least 70% can describe at least one thing the staff told them about why testing and
counselling for HIV is important for pregnant women.
at least 70% can describe at least one thing the staff told them about what a HIV-
positive mother needs to consider when deciding how to feed her baby.
Mother-friendly care (optional)

Note: The national authorities will determine whether or not maternity services should be assessed
on whether they meet the criteria related to mother-friendly care.
Global Criteria – Mother-friendly care

Note: A decision will be made by the national BFHI coordination group and other appropriate
national decision-makers as to whether the criteria related to mother-friendly care will be
included in the BFHI assessment.
A review of the hospital policies indicates that they require mother-friendly labour and
birthing practices including:
encouraging women to have companions of their choice to provide continuous
physical and/or emotional support during labour and birth, if desired
allowing women to drink and eat light foods during labour, if desired
encouraging women to consider the use of non-drug methods of pain relief unless
analgesic or anaesthetic drugs are necessary because of complications, respecting the
personal preferences of the women
encouraging women to walk and move about during labour, if desired, and assume
positions of their choice while giving birth, unless a restriction is specifically required
for a complication and the reason is explained to the mother
care that does not involve invasive procedures such as rupture of the membranes,
episiotomies, acceleration or induction of labour, instrumental deliveries, or
caesarean sections unless specifically required for a complication and the reason is
explained to the mother
at least 80% are able to describe at least two recommended practices that can help a
mother be more comfortable and in control during labour and birth
at least 80% are able to list at least three labour or birth procedures that should not be
used routinely, but only if required due to complications
at least 80% are able to describe at least two labour and birthing practices that make it
more likely that breastfeeding will get off to a good start
Out of the randomly selected pregnant women:
at least 70% report that the staff has told them women can have companions of their
choice with them throughout labour and birth and at least one reason it could be
helpful
at least 70% report that they were told at least one thing by the staff about ways to
deal with pain and be more comfortable during labour, and what is better for mothers,
babies and breastfeeding
Acceptable medical reasons for supplementation (DRAFT)
Exclusive breastfeeding is the norm. In a small number of situations there may be a medical
indication for supplementing breastmilk or for not using breastmilk at all. It is useful to
distinguish between:
o infants who cannot be fed at the breast but for whom breastmilk remains the food of
choice;
o infants who may need other nutrition in addition to breastmilk;
o infants who should not receive breastmilk, or any other milk, including the usual
breastmilk substitutes and need a specialised formula;
o infants for whom breastmilk is not available;
o maternal conditions that affect breastfeeding recommendations.
Infants who cannot be fed at the breast but for whom breastmilk remains the food of
choice may include infants who are very weak, have sucking difficulties or oral abnormalities, or
are separated from their mother who is providing expressed milk. These infants may be fed
expressed milk by tube, cup, or spoon.
Infants who may need other nutrition in addition to breastmilk may include very low birth
weight or very preterm infants, i.e., those born less than 1500 g or 32 weeks gestational age;
infants who are at risk of hypoglycaemia because of medical problems, when sufficient
breastmilk is not immediately available; infants who are dehydrated or malnourished when
breastmilk alone cannot restore the deficiencies. These infants require an individualised feeding
plan, and breastmilk should be used to the extent possible. Efforts should be made to sustain
maternal milk production by encouraging expression of milk. Milk from tested milk donors may
also be used. Hind milk is high in calories and particularly valuable for low birth weight infants.
Infants who should not receive breast milk, or any other milk, including the usual
breastmilk substitutes may include infants with certain rare metabolic conditions such as
galactosemia who may need feeding with a galactose free special formula or phenylketonuria
where some breastfeeding may be possible, partly replaced with phenylalanine free formula.
Infants for whom breastmilk is not available may include when the mother had died, or is
away from the baby and not able to provide expressed breastmilk. Breastfeeding by another
woman may be possible; or the need for a breastmilk substitute may be only partial or
temporary. There are a very few maternal medical conditions where breastfeeding is not
recommended.
Maternal conditions that may affect breastfeeding recommendations include where the
mother is physically weak, is taking medications, or has an infectious illness.
o A weak mother may be assisted to position her baby so her baby can breastfeed.
o A mother with a fever needs sufficient fluids.
Maternal medication
If mother is taking a small number of medications such as anti-metabolites, radioactive iodine,
or some anti-thyroid medications, breastfeeding should stop during therapy.
Some medications may cause drowsiness or other side effects in the infant. Check medications
with the WHO list, and where possible choose a medication that is safer and monitor the infant
for side effects, while breastfeeding continues.
Maternal addiction
Even in situations of tobacco, alcohol and drug use, breastfeeding remains the feeding method
of choice for the majority of infants. If mother is an intravenous drug user, breastfeeding is not
indicated.
HIV-infected mothers
When replacement feeding is acceptable, feasible, affordable, sustainable and safe, (AFASS)
avoidance of all breastfeeding by HIV-infected mothers is recommended. Otherwise, exclusive
breastfeeding is recommended during the first months of life, and should then be discontinued
as soon as the specified conditions are met. Mixed feeding (breastfeeding and giving
replacement feeds at the same time), is not recommended.
Other maternal infectious illnesses
Breast abscess - feeding from the affected breast is not recommended but milk should be
expressed from the breast. Feeding can be resumed once the abscess has been drained and
the mother’s treatment with antibiotics has commenced. Breastfeeding should continue on the
unaffected breast.
Herpes Simplex Virus Type I (HSV-1) – Women with herpes lesions on their breasts should
refrain from breastfeeding until all active lesions on the breast have resolved.
Varicella-zoster – Breastfeeding of a newborn infant is discouraged while the mother is
infectious, but should be resumed as soon as the mother becomes non-infectious.
Lyme disease – Breastfeeding may continue during mother’s treatment.
HTLV-I (Human T-cell leukaemia virus) - breastfeeding is not encouraged if safe and feasible
options (AFASS) for replacement feeding are available.
Maternal conditions of common concern for which breastfeeding is not

contraindicated
Hepatitis B: Infected mothers should continue breastfeeding as usual. Infants should be given
hepatitis B vaccine, within the first 48 hours or as soon as possible thereafter.
Tuberculosis: Breastfeeding by the TB-positive mother should be continued as usual. Mother
and baby should be managed according to national tuberculosis guidelines.
Mastitis: In general, continued breastfeeding is recommended during antibiotic therapy.
References:
Available from Child and Adolescent Health, WHO, Geneva
http://www.who.int/child-adolescent-health/publications/pubnutrition.htm
HIV transmission through breastfeeding. A review of available evidence (2004) ISBN 92 4
159271 4
Breastfeeding and Maternal Medication: Recommendations for Drugs in the UNICEF/WHO
Eleventh WHO Model List of Essential Drugs. Geneva: World Health Organization, 2002
39
SECTION 1.4
COMPLIANCE WITH THE INTERNATIONAL CODE
OF MARKETING OF BREASTMILK SUBSTITUTES
What is the Code?

The Code was adopted in 1981 by the World Health Assembly to promote safe and
adequate nutrition for infants, by the protection and promotion of breastfeeding and by
ensuring the proper use of breast-milk substitutes, when these are necessary. One of the
main principles of the Code is that health care facilities should not be used for the
purpose of promoting breastmilk substitutes, feeding bottles or teats. Subsequent WHA
resolutions have clarified the Code and closed loopholes.
How is the Code relevant to the Baby-Friendly Hospital Initiative?

In launching the BFHI in 1991, UNICEF and WHO were hoping to ensure that all
maternities would become centres of breastfeeding support. In order to achieve this,
hospitals must avoid being used for the promotion of breastmilk substitutes, bottles or
teats, or the distribution of free formula. The Code, together with the subsequent
relevant Resolutions of the World Health Assembly, lays down the basic principles
necessary for this. In addition, in adopting the Code in 1981, the World Health
Assembly called upon health workers to encourage and protect breastfeeding, and to
make themselves familiar with their responsibilities under the Code.
Which products fall under the scope of the Code?

The Code applies to breastmilk substitutes, including infant formula; other milk
products, foods and beverages, including bottle-fed complementary foods, when
marketed or otherwise represented to be suitable, with or without modification, for use
as a partial or total replacement of breastmilk; feeding bottles and teats.
Since exclusive breastfeeding is to be encouraged for 6 months, any food or drink
shown to be suitable for feeding a baby during this period is a breastmilk substitute, and
thus covered by the Code. This would include baby teas, juices and waters. Special
formulas for infants with special medical or nutritional needs also fall under the scope
of the Code.
Since continued breastfeeding is to be encouraged for two years or beyond, any milk
product shown to be substituting for the breastmilk part of the child’s diet between six
months and two years, such as follow-on formula, is a breastmilk substitute and is thus
covered by the Code.
What does the Code say?

The main points in the Code include:
• No advertising of breastmilk substitutes and other products to the public
• No free samples to mothers
• No promotion in the health services
• No donations of free or subsidized supplies of breastmilk substitutes or other
products in any part of the health care system
• No company personnel to contact or advise mothers
• No gifts or personal samples to health workers
Section 1.4: Compliance with the International Code 40
• No pictures of infants, or other pictures or text idealizing artificial feeding, on

the labels of the products.
• Information to health workers should only be scientific and factual.
• Information on artificial feeding should explain the benefits of breastfeeding and
the costs and dangers associated with artificial feeding.
• Unsuitable products, such as sweetened condensed milk, should not be promoted
for babies.
Who is a “health worker” for the purposes of the Code?

According to the Code, any person working in the health care system, whether
professional or non-professional, including voluntary and unpaid workers, in public or
private practice, is a health worker. Under this definition, ward assistants, sweepers,
nurses, midwives, social workers, dieticians, counsellors, in-hospital pharmacists,
obstetricians, administrators, clerks, etc. are all health workers.
What are a health worker’s responsibilities under the Code?

1. Encourage and protect breast-feeding. Health workers involved in maternal and
infant nutrition should make themselves familiar with their responsibilities under the
Code, and be able to explain the following:
• the benefits and superiority of breastfeeding;
• maternal nutrition, and the preparation for and maintenance of breastfeeding;
• the negative effect on breastfeeding of introducing partial bottle-feeding;
• the difficulty of reversing the decision not to breastfeed; and
• where needed, the proper use of infant formula, whether manufactured
industrially or home-prepared.
When providing information on the use of infant formula, health workers should be able
to explain:
• the social and financial implications of its use;
• the health hazards of inappropriate foods or feeding methods; and
• the health hazards of unnecessary or improper use of infant formula and other
breastmilk substitutes.
2. Ensure that the health facility is not used for the display of products within the
scope of the Code, for placards or posters concerning such products. Ensure that
packages of breastmilk substitutes and other supplies purchased by the health facility
are not on display or visible to mothers
3. Refuse any gifts offered by manufacturers or distributors.
4. Refuse samples (meaning single or small quantities) of infant formula or other
products within the scope of the Code, or of equipment or utensils for their preparation
or use, unless necessary for the purpose of professional evaluation or research at the
institutional level.
5. Never pass any samples to pregnant women, mothers of infants and young children,
or members of their families.
6. Disclose any contribution made by a manufacturer or distributor for fellowships,
study tours, research grants, attendance at professional conferences, or the like to
management of the health facility.
7. Be aware that support and other incentives for programmes and health professionals
working in infant and young-child health should not create conflicts of interests.
Does the Code ban all free and low-cost supplies of infant formula and other
breastmilk substitutes (including follow-on formula) in health facilities?
Yes. Although there were some ambiguities in the wording of Articles 6.6 and 6.7 of the
Code, these were clarified in 1994 by World Health Assembly Resolution (WHA 47.5)
which urged Governments:
“to ensure that there are no donations of free or subsidized supplies of breast-
milk substitutes and any other products covered by the International Code of
Marketing of Breast-milk Substitutes in any part of the health care system”
Breastmilk substitutes should be obtained through “normal procurement channels” so as
not to interfere with the protection and promotion of breastfeeding. Procurement means
purchase.
Should free supplies be donated for pre-term and low birth weight infants? Some
argue that these infants need early supplementation, and therefore free supplies
should be permitted.
No. The prohibition applies to all types of infant formula, including those for special
medical purposes. In any case, breastmilk is the medically indicated feeding of choice
for almost all pre-term and low birth weight babies.14 Obtaining free supplies for these
babies encourages bottle (artificial) feeding, which further threatens their survival and
healthy development.
Moreover, once free supplies are available in the maternities and nurseries, it is
extremely difficult to control their distribution and misuse.
Should free supplies be donated for infants of HIV-positive mothers who have
chosen to formula feed?
No. As stated above, once free supplies are available in the health care system it is
virtually impossible to prevent their misuse and the undermining of breastfeeding.
Governments should procure the formula needed through normal procurement channels.
Should the prohibition extend to Maternal Child Health, primary health, and
rural clinics?
Yes. The Code defines the health care system as: “governmental, non-governmental or
private institutions or organizations engaged, directly or indirectly, in health care for
mothers, infants and pregnant women; and nurseries or child-care institutions. It also
includes health workers in private practice.”
Why not permit free supplies in paediatric wards, since older infants may already
be using feeding bottles?
Because free supplies to paediatric services or other special services for sick infants can
seriously undermine breastfeeding. The WHO/UNICEF guidelines suggest, in
paragraph 50:
“There will, of course, always be a small number of infants in these services
who will need to be fed on breastmilk substitutes. Suitable substitutes, procured
and distributed as part of the regular inventory of foods and medicines of any
such health care facility, should be provided for those infants.”
14
See WHO/UNICEF “Guidelines concerning the main health and socioeconomic circumstances in which infants
have to be fed on breastmilk substitutes” (WHO, A39/8 Add. 1, 10 April 1986). The 1986 World Health Assembly
based its adoption of WHA 39.28 on this document.
Is there a working definition for “low-cost” supplies?

Yes. There is a general agreement that ending “low-cost” or “low-price” sales means
ending sales at prices below the wholesale price or lower that 80 percent of the retail
price, in the absence of a standard wholesale price. The reason for stopping low price
sales is that low prices lead to the overuse of breastmilk substitutes.
Is the Code still relevant in view of the HIV pandemic and the increased need for
formula?
Yes. Indeed the Code is even more important in the context of HIV, since the Code and
resolutions:
• encourage governments to regulate the distribution of free or subsidized supplies
of breastmilk substitutes to prevent “spillover”;
• protect children fed on replacement foods by ensuring that product labels carry
necessary warnings and instructions for safe preparation and use;
• ensure that a given product is chosen on the basis of independent medical
advice.
The Code is relevant to, and fully covers the needs of, mothers who are HIV-positive.
Even where the Code has not been implemented, its provisions still apply.
43
SECTION 1.5:
BABY-FRIENDLY EXPANSION AND
INTEGRATION POSSIBILITIES
Over the last 15 years of work on BFHI, many lessons have been learned. Perhaps the
clearest lesson is the need for more attention to Step 10 and the community. Another
pressing issue has been the need to rectify the misunderstandings concerning the
appropriateness of BFHI in the context of the HIV pandemic. Other issues that have
arisen and been addressed in some countries are the need to ensure mother-friendly care,
breastfeeding supportive paediatric care, NICUs and physician’s offices, and last, but by
no means least, the need for the mother of the exclusively breastfed child to be supported
to understand the need for the age-appropriate addition of complementary foods after 6
months.
Current trends in health system and related planning indicate the need for increased
flexibility, integration, and complementarity among interventions. For this reason, and
to aid countries in creating synergy in their programmes and in actively addressing
identified issues, a variety of alternative approaches are now included in the BFHI
materials. These expansion and integration options are intended to create the possibility
for more creative and supportive mother and baby-friendly care.
Presented below are a few of the many variations that have been tried around the world
in order to bring truly Baby-friendly Care to all.
Baby-Friendly communities: Creating Step Ten

Step 10, of all of the Ten Steps, has not achieved full implementation in a wide variety
of settings, although many options are suggested, including mother-to-mother or peer
groups, organised support by certified lactation consultants, regular outreach by the
maternity staff especially in the first days postpartum, referral to community-based
primary health care centres with specialized training, hotlines, etc. Efforts to date have
not been optimal due to a variety of factors, not the least of which is that facility-based
personnel may simply not have the skills to create community mobilization. In addition,
often there is reliance on volunteers to carry out ongoing activities, so it is necessary to
have regular refreshers and support activities for ongoing motivation and
communication.
Perhaps of most relevance to reaching the most vulnerable populations is the reality that
most deliveries in developing countries occur in the communities and even the initial
Baby-friendly care may not be in place
A new initiative – Baby-friendly Communities – has been developed in some countries,
and can serve as a model
1. for expanding BFHI practices and criteria into community health services,
2. for expanding BFHI practices into delivery settings where there are no community
health services,
3. for strengthening the vital tenth step in ensuring best practices and support for
every mother
Section 1.5: Expansion and Integration 44
Suggestions for national criteria that could be applied in these three situations:
These Model National Baby-friendly Community components are

provided as a model for community discussion of needs, reflecting on
all applicable Global Criteria for the BFHI (the Ten Steps).
Locally developed criteria should minimally include attention to:

1. Community political and social leadership, both male and female, are
committed to making a change in support of optimal infant and young
child feeding.
2. All health facilities that include maternity services, or local health care
provision, are designated “Baby-friendly” and actively support both early
and exclusive breastfeeding (0-6 months).
3. If home deliveries are the norm, all who assist in deliveries are informed
concerning the importance of delayed cord cutting, immediate skin-to-
skin continued for at least 60 minutes, and no prelacteal feeds.
4. All who assist in facility-based or home deliveries are informed
concerning mother-friendly labour and birthing practices such as
encouraging mothers to have companions to provide support, minimizing
invasive procedures unless medically necessary, encouraging women to
move about and assume positions of their choice during labour, etc.(See
“mother-friendly” section).
5. Community access to referral site(s) with skilled support for early,
exclusive and continued breastfeeding is available.
6. Support is available in community for age-appropriate, frequent, and
responsive complementary feeding with continued breastfeeding. This
will generally mean that there is availability of micronutrients or animal-
based foods and adequate counselling to assist mothers in making
appropriate choices.
7. Mother-to-mother support system, or similar, is in place.
8. No practices, distributors, shops or services violate the International Code
(as applicable) in the community.
9. Local government or civil society has convened, created and supports
implementation of at least one political or social normative change and/or
additional activity that actively supports mothers and families to succeed
with immediate and exclusive breastfeeding practices (e.g. time-sharing
of tasks, granting authority to transport breastfeeding mothers for referral
if needed, identification of “breastfeeding advocates/protectors” among
community leaders, breastfeeding supportive workplaces, etc.).
10. Simplified job-aids for assisting and for assessing home deliveries
(including those performed by skilled midwives and, if possible,
traditional birth attendants,) have been developed and are in use.
Example from Gambia

An excellent example of an innovative approach to this problem and its solution is
found in the “The Baby Friendly Community Initiative (BFCI) – An Expanded Vision
for Integrated Early Childhood Development in the Gambia”. The full text of this
document will be available on the UNICEF internet.
In summary, BFHI was used as the model for the development of the Baby-friendly
Community Initiative (BFCI). The BFCI includes 10 steps to successful infant feeding
incorporating maternal nutrition, infant nutrition, environmental sanitation and personal
hygiene. In other settings, safe delivery or child and maternity protection might have
greater relevance. In Gambia, communities identified 5 women and 2 men each, to be
trained and certified “Village Support Groups on Infant Feeding”. When the 10 steps
developed by the community are implemented, the community is designated a “Baby
Friendly Community”.
Training of community representatives as Village Support Groups on infant feeding was
considered the most important element of the BFCI. Men’s involvement in the BFCI
both as members of the Support Groups and as part of the target population may also be
a crucial element for success and sustainability of the intervention. Their involvement in
an area, which in the past targeted only women, sent out a clear and strong message that
maternal and infant nutrition concerned both men (fathers) and women (mothers).
World Breastfeeding Week may be used as an entry point to bring together targeted
politicians, Senior Government and NGO officials, as well as international Agencies for
sensitization to create better understanding of the importance of breastfeeding, what has
already occurred in country, and what may be possible, and create a cadre of high level
support.
In Gambia, such a meeting led to recommendations:
1. Intensified information, education and communication (IEC) activities to eradicate
taboos and other traditional practices, which affect the practice of optimal
breastfeeding;
2. Inclusion of breastfeeding in the curricula of schools and training institutions;
3. Setting up of support groups on breastfeeding;
4. Extended maternity leave for working mothers;
5. Development of breastfeeding policies;
6. Similar seminars at the regional and community levels;
7. The implementation of the Baby-Friendly Hospital Initiative;
8. Ensuring community involvement
The results of this approach in Gambia were an increase from 60% to 100% in initiation
of breastfeeding in the first day of live, and a decline in introduction of complementary
feeding at four months of age from 90% to nearly 0%.
In Gambia, the BFHI also helped introduce other community based services that meet
the needs of infants and young children are vital to many health, growth and
development intervention approaches, including bed nets, HIV/AIDS awareness,
immunization support, and reproductive health care. The approach promotes and
protects the rights of the child to survival, growth and development.
The Ten Steps to Successful Breastfeeding in the Community:

The Gambia’s Baby-friendly Community Initiative
Every village should have an enabling environment for mothers to practice
optimal breastfeeding. Therefore, a trained Village Support Group on infant
feeding:
1. Informs and advises all pregnant and lactating women and their spouses on
the importance of an adequate maternal diet using locally available foods by
explaining the benefits to both maternal and infant health.
2. Informs all pregnant women and their spouses about the benefits of breast
milk including colostrum.
3. Advises and encourages mothers to initiate breastfeeding within an hour after
birth and not to give any prelacteal feeds unless on the advice of a medical
personnel.
4. Informs both mothers and fathers about the benefits of exclusive breastfeeding
and encourages all mothers of healthy newborns to breastfeed exclusively for
six months.
5. Informs both mothers and fathers about the hazards and cost of bottle-
feeding, the use of formula and the use of pacifiers (comforters).
6. Ensures that orphans get breast milk by encouraging the traditional practice
of wet nursing for babies who have lost their mothers at birth.
7. Advises and encourages mothers to introduce locally available
complementary foods when the infant is six months of age.
8. Advises and encourages all mothers to use fermented cereal in the
preparation of the complementary feeding pap by telling them about the
benefits.
9. Teaches all mothers and caregivers about the benefits of adequate personal
hygiene and environmental sanitation to infant health, including the basic
principles for the preparation of safe foods for infants and young children.
10. Encourages mothers to support each other to practice optimal breastfeeding
by forming their own informal support groups on infant feeding.
BFHI and Prevention of Mother to Child Transmission (PMTCT) of HIV/AIDS

The WHO/UNICEF guidance on infant feeding support for HIV-positive mothers
strongly suggest that training on support for exclusive breastfeeding precede training on
feeding options for HIV-positive mothers. For this reason, Malawi, among other
countries, has decided that BFHI must be in place at the same time as the initiation of
counselling for the HIV-positive mothers.
The rationale is at least 3 fold:
1. Since exclusive breastfeeding is an option for all mothers, the establishment of
excellence in support of exclusive breastfeeding will benefit all.
2. For HIV-positive mothers for whom replacement feeding in not acceptable, feasible,
affordable, sustainable and safe, exclusive breastfeeding is the recommended option.
3. If all counsellors understand the importance of exclusive breastfeeding, spill over
and over use of artificial foods will be reduced.
4. Recent research findings indicate that exclusive breastfeeding may reduce the
passage of HIV via breastmilk, when compared to mixed feeding.
If this last item is proven to be consistent in additional studies, then exclusive
breastfeeding among the greater population of HIV-infected women who have not been
diagnosed as yet will provide a double benefit.
Mother-Baby friendly facilities and communities

The Mother-Friendly Childbirth Initiative includes the “Ten Steps of the Mother-
Friendly Childbirth Initiative for Mother-Friendly Hospitals, Birth Centers, and Home
Birth Services” and can be initiated in concert with baby-friendly initiatives and as an
integrated mother-baby aspect of a maternal-child care continuum.
The Mother-Friendly Childbirth Initiative was initially developed in 1996 by the
Coalition for Improving Maternity Services (CIMS) with the First Consensus Initiative.
CIMS is a coalition of individuals and national organizations with concern for the care
and well-being of mothers, babies, and families. The mission is to promote a wellness
model of maternity care that will improve birth outcomes and substantially reduce costs.
This evidence-based mother-, baby-, and family-friendly model focuses on prevention
and wellness as the alternatives to high-cost screening, diagnosis, and treatment
programs. The suggested “Ten steps” is based on the recognition that some current
maternity and newborn practices both contribute to high costs and inferior outcomes,
such as inappropriate application of technology and routine procedures that are not
based on scientific evidence. The principles of this approach is respect for the normalcy
(i.e., non-medical) of the birthing process, the autonomy and empowerment of the
woman, caregiver responsibility and doing “no harm”
The Mother Baby-friendly Ten Steps presented here are modified to allow integration
with current continuum of care approaches.
Suggested Mother-Baby-friendly Ten Steps for consideration

in developing national criteria in coordination with Baby-friendly:
A mother-baby-friendly hospital, birth center, or home birth:
1. Provides or refers for antenatal care, including vitamin/iron/folate supplementation,
malaria prophylaxis, HIV-testing, monitoring for danger signs, and referral where
appropriate.
2. Offers all birthing mothers:
Unrestricted access to the birth companions of her choice, including fathers,
partners, children, family members, and friends.
Unrestricted access to continuous emotional and physical support from a skilled
woman-for example, a doula or labor-support professional.
Access to the best available care, preferably skilled assistance and access to
timely referral as needed.
The freedom to walk, move about, and assume the positions of her choice during
labor and birth (unless restriction is specifically required to correct a
complication), and discourages the use of the lithotomy15 position.
3. Maintains records to allow for external and self-assessment and reporting purposes.
4. Provides culturally competent care - that is, care that is sensitive and responsive to
the specific beliefs, values, and customs of the mother's ethnicity and religion.
5. Has clearly defined policies and procedures for:
Clean birthing techniques
Delayed cord clamping
Placenta removal and disposal
Collaboration, consultation and referral with other maternity services, including
maintaining communication with all caregivers when referral/transfer is necessary;
Linking the mother and baby to appropriate community resources, including
prenatal and post-discharge follow-up and breastfeeding support.
6. Does not routinely employ practices and procedures that are unsupported by
scientific evidence, including but not limited to the following:
shaving; enemas; IVs (intravenous drip); withholding nourishment; early rupture
of membranes; electronic fetal monitoring.
Other interventions are limited as follows:
has an induction rate of 10% or less;
has an episiotomy rate of 20% or less, with a goal of 5% or less;
has a total cesarean rate of 10% or less in community hospitals, and 15% or
less in tertiary care (high-risk) hospitals;
has a VBAC (vaginal birth after cesarean) rate of 60% or more with a goal of
75% or more.
7. Educates staff in non-drug methods of pain relief and does not promote the use of
analgesic or anesthetic drugs not specifically required to correct a complication.
8. Encourages all mothers and families, including those with sick or premature
newborns or infants with congenital problems, to touch, hold, breastfeed, and care
for their babies to the extent compatible with their conditions.
9. Has training in hemorrhage control, both manual and medical.
10. Strives to achieve the WHO-UNICEF Ten Steps of the Baby-Friendly Hospital
Initiative to promote successful breastfeeding.
15
To lie flat on back with legs elevated
Key aspects of “mother-friendly care” have been integrated into the revised 20-hour
Course, Global Criteria and assessment process for BFHI, as an optional module. This
provides countries with an easy way to begin the process of integrating mother-friendly
childbirth practices into their maternity services, if they do not yet have a full-fledged
initiative of the type described above.
Baby-friendly Neonatal Intensive Care and Paediatric Units

Whereas BFHI is maternity based, its impact in support of post-discharge breastfeeding
is limited to its community outreach – Step Ten. Therefore, the concept of baby-friendly
paediatrics was considered. The following 10 steps are derived from the suggested 11
Steps developed in Australia16 and are built upon the BFHI:
10 Steps to Optimal Breastfeeding in Paediatrics

1. Have a written breastfeeding policy and train staff in necessary skills
2. When an infant is seen, for either a well visit or due to illness, ascertain the
mother’s infant feeding practices, and assist in establishment or
management of breastfeeding as needed
3. Provide parents with written and verbal information about breastfeeding
4. Facilitate unrestricted breastfeeding or, if necessary, milk expression for
mothers regardless of the child’s age
5. Give breastfed children other food or drink only when age appropriate or
when medically indicated, and if medically indicated, use only alternative
feeding methods most conducive to return to breastfeeding
6. If hospitalization is needed, ensure facility allows 24-hour mother/child
rooming in
7. Administer medications and schedule procedures so as to cause the least
possible disturbance of feeding
8. Maintain a human milk bank, according to standards.
9. Provide information and contacts concerning community support available
10. Maintain appropriate monitoring and records/data collection procedures to
permit quality assurance assessment, progress rounds or staff meetings, and
feedback
The issue of transitioning the baby from an NICU setting to home is also extremely
important. Items to include in consideration of Baby-friendly treatment of the premature
or ill infant should include criteria or standards for care, discharge panning, post-
discharge assessment, and special support for mothers.
16
Donohue L, Minchin M and C Minogue, 11 Step approach to Optimal Breastfeeding in the Paediatric Unit
Breastfeeding Review, Nov 1996, 4(2):88
The Academy for Breastfeeding Medicine, International, in cooperation with US

Department of Health and Human Services, WHO and UNICEF, has developed many
protocols that may serve as a basis for national development of criteria for Baby-
friendly Paediatrics or Baby-friendly NICUs. These protocols are posted and updated
regularly. ABM is dedicated to continuing the development and dissemination of these
standards for practice on their website: http://www.bfmed.org/protocols.html
Baby-friendly Physician’s Office: Optimizing Care for Infants and Children

This guidance is derived from the ABM draft protocol which is available in full on their
website. This is presented for consideration in the development of criteria for Baby-
friendly Physician Offices.
Issues to consider in developing criteria for Baby-friendly Physician Offices17

1. Establish a written breastfeeding friendly office policy and inform all new staff about
the policy.
2. Encourage breastfeeding mothers to exclusively breastfeed. Instruct mother not to
offer bottles or a pacifier till breastfeeding is well established.
3. Offer culturally and ethnically competent care.
4. Offer a prenatal visit and show your commitment to breastfeeding during this visit.
5. Collaborate with local hospitals and maternity care professionals in the community.
Convey to delivery rooms and newborn units your office policies on breastfeeding
initiation.
6. Schedule a first follow-up visit 48-72 hours after hospital discharge or earlier if
breastfeeding related problems, such as excessive weight loss (>7%) or jaundice
are present at the time of hospital discharge.
7. Ensure availability of appropriate educational resources for parents. Educational
material should be non-commercial and not advertise breast milk substitutes, bottles
and nipples.
8. Do not interrupt or discourage breastfeeding in the office. Allow and encourage
breastfeeding in the waiting room. Ensure an office environment that demonstrates
breastfeeding promotion and support.
9. Develop and follow triage protocols to address breastfeeding concerns and
problems.
10. Commend breastfeeding mothers during each visit for choosing and continuing
breastfeeding.
11. Encourage mothers to exclusively breastfeed for 6 months and continue
breastfeeding with complementary foods until at least 24 months and thereafter as
long as mutually desired. Discuss introduction of solid food at 6 months of age,
emphasizing the need for high-iron solids and assess for need for vitamin D
supplementation.
12. Have a written breastfeeding policy and provide a lactation room with supplies for
your employees who breastfeed or express breast milk at work. Encourage
community employers and day care providers to support breastfeeding.
13. Acquire or maintain a list of community resources and support local breastfeeding
support groups.
17
Modified from ABM Protocol
14. Work with insurance companies to encourage coverage of breast pump costs and
lactation support services.
15. All clinicians and physicians should receive education regarding breastfeeding.
Volunteer to let medical students and residents rotate in your practice. Participate in
medical student and resident physician education. Encourage establishment of
formal training programs in lactation for future and current healthcare providers.
16. Monitor breastfeeding initiation and duration rates in your practice, and analyse what
additional changes can be made to enhance your support for optimal infant and
young child feeding.
Baby-friendly Complementary Feeding

Breastfeeding and complementary feeding are a continuum; consideration of one must
include consideration of the other. As the name indicates, “complementary” feeding is a
complement to breastfeeding. Complementary feeding is essential for continued growth
after 6 months of age. New recommendations for the addition of first foods into the diet
emphasize protein and micronutrients in addition to energy needs.
The Ten Guiding Principles of Complementary Feeding serve as a guide for feeding
behaviours, and as BFHI is integrated with other programmes, there will be an
increasing number of opportunities to build on its messages.
TEN GUIDING PRINCIPLES FOR COMPLEMENTARY FEEDING18
1. DURATION OF EXCLUSIVE BREASTFEEDING AND AGE OF INTRODUCTION OF

COMPLEMENTARY FOODS. Practice exclusive breastfeeding from birth to 6 months of
age, and introduce complementary foods at 6 months of age (180 days) while continuing to
breastfeed.
2. MAINTENANCE OF BREASTFEEDING. Continue frequent, on-demand breastfeeding
until 2 years of age or beyond.
3. RESPONSIVE FEEDING. Practice responsive feeding, applying the principles of
psychosocial care. Specifically: a) feed infants directly and assist older children when they
feed themselves, being sensitive to their hunger and satiety cues; b) feed slowly and
patiently, and encourage children to eat, but do not force them; c) if children refuse many
foods, experiment with different food combinations, tastes, textures and methods of
encouragement; d) minimize distractions during meals if the child loses interest easily; e)
remember that feeding times are periods of learning and love - talk to children during
feeding, with eye to eye contact.
4. SAFE PREPARATION AND STORAGE OF COMPLEMENTARY FOODS. Practice
good hygiene and proper food handling by a) washing caregivers’ and children’s hands
before food preparation and eating, b) storing foods safely and serving foods immediately
after preparation, c) using clean utensils to prepare and serve food, d) using clean cups
and bowls when feeding children, and e) avoiding the use of feeding bottles, which are
difficult to keep clean.
18 PAHO (2003). Guiding principles for complementary feeding of the breastfed child. The whole document can be
downloaded from http://www.who.int/child-adolescent-health/NUTRITION/infant.htm
5. AMOUNT OF COMPLEMENTARY FOOD NEEDED. Start at 6 months of age with small

amounts of food and increase the quantity as the child gets older, while maintaining
frequent breastfeeding. The energy needs from complementary foods for infants with
"average" breast milk intake in developing countries are approximately 200 kcal per day at
6-8 months of age, 300 kcal per day at 9-11 months of age, and 550 kcal per day at 12-23
months of age. In industrialized countries these estimates differ somewhat (130, 310 and
580 kcal/d at 6-8, 9-11 and 12-23 months, respectively) because of differences in average
breast milk intake.
6. FOOD CONSISTENCY. Gradually increase food consistency and variety as the infant
gets older, adapting to the infant’s requirements and abilities. Infants can eat pureed,
mashed and semi-solid foods beginning at six months. By 8 months most infants can also
eat "finger foods" (snacks that can be eaten by children alone). By 12 months, most
children can eat the same types of foods as consumed by the rest of the family (keeping in
mind the need for nutrient-dense foods, as explained in #8 below). Avoid foods that may
cause choking (i.e., items that have a shape and/or consistency that may cause them to
become lodged in the trachea, such as nuts, grapes, raw carrots).
7. MEAL FREQUENCY AND ENERGY DENSITY. Increase the number of times that the
child is fed complementary foods as he/she gets older. The appropriate number of feedings
depends on the energy density of the local foods and the usual amounts consumed at each
feeding. For the average healthy breastfed infant, meals of complementary foods should be
provided 2-3 times per day at 6-8 months of age and 3-4 times per day at 9-11 and 12-24
months of age, with additional nutritious snacks (such as a piece of fruit or bread or
chapatti with nut paste) offered 1-2 times per day, as desired. Snacks are defined as foods
eaten between meals-usually self-fed, convenient and easy to prepare. If energy density or
amount of food per meal is low, or the child is no longer breastfed, more frequent meals
may be required.
8. NUTRIENT CONTENT OF COMPLEMENTARY FOODS. Feed a variety of foods to
ensure that nutrient needs are met. Meat, poultry, fish or eggs should be eaten daily, or as
often as possible. Vegetarian diets cannot meet nutrient needs at this age unless nutrient
supplements or fortified products are used (see #9 below). Vitamin A-rich fruits and
vegetables should be eaten daily. Provide diets with adequate fat content. Avoid giving
drinks with low nutrient value, such as tea, coffee and sugary drinks such as soda. Limit
the amount of juice offered so as to avoid displacing more nutrient-rich foods.
9. USE OF VITAMIN-MINERAL SUPPLEMENTS OR FORTIFIED PRODUCTS FOR
INFANT AND MOTHER. Use fortified complementary foods or vitamin-mineral
supplements for the infant, as needed. In some populations, breastfeeding mothers may
also need vitamin mineral supplements or fortified products, both for their own health and
to ensure normal concentrations of certain nutrients (particularly vitamins) in their breast
milk. [Such products may also be beneficial for pre-pregnant and pregnant women].
10. FEEDING DURING AND AFTER ILLNESS. Increase fluid intake during illness,
including more frequent breastfeeding, and encourage the child to eat soft, varied,
appetizing, favourite foods. After illness, give food more often than usual and encourage
the child to eat more.
The two figures that follow, emphasis the need to support continued breastfeeding from
6 months to 2 years or longer to meet the baby’s growing needs in addition to suitable
complementary foods.
Figure 1: 19
Percentage of nutrients from 550cc of breastmilk, and needs remaining to be
supplied by complementary foods in the second year of life
100%
75%
Percent still needed from

50% Complementary Foods
Percent from Breastmilk
25%
0%
Energy Protein Iron Vitamin
A
Figure 2:20
Minimum dietary energy density required to attain the level of energy needed
from complementary foods in one to five meals per day, according to age group
and level (low, average, or high) of breastmilk energy intake (BME).
This figure conveys the necessity of maintaining high volumes of milk for energy while
adding a sufficient number of meals, dependent on their nutrient density.
19
From the WHO/UNICEF Infant and Young Child Feeding Counselling: An Integrated Course
20
From Dewey K and K Brown, Update on technical issues concerning complementary feeding of young children in
developing countries and implications for intervention programs. Food and Nutrition Bulletin; 24(1): 8, in Daelmans
B, Martines J and R Saadeh (eds), Special Issue Based on a World Health Organization Expert Consultation on
Complementary Feeding
How might complementary feeding be addressed in Baby-friendly Care? There are

many options.
• If BFHI has expanded into the paediatrics areas, it may include the “Ten
Principles” of complementary feeding and use of the new growth charts.
• If Baby-friendly communities are in place, locally available foods may be
identified for best feeding at this age.
• If BFHI Step Ten has reached out to community workers, whether from the
health, agricultural, educational, or lay sectors, their training and efforts can
include the ten principles.
In all cases, collection of data on feeding patterns and content by age of child, whether
ongoing or periodic, will provide invaluable feedback for programme improvement.
Mother-baby friendly health care - everywhere!

The principles of mother-child centred care, protection of optimal mother and child
conditions, and the recognition that maternal-child dyad deserves respect and support,
are the underlying principles of all of these mother and baby-friendly expansion
possibilities, and can be translated to a wide variety of environments, including:
• Hospitals, including all paediatric and women’s health care units, as well as
general medicine and surgery
• Other health care facilities such as clinics, MCH centre, etc.
• Community outreach and mobilization programs.
• Faith based communities
• Physician’s offices
• International initiatives, such as Community IMCI, partnership activities,
Accelerated Child Survival and others.
The Baby-friendly activity may be added into one of these other efforts, or vice versa.
The priority must be to ensure a comprehensive approach to support for Infant and
Young Child Feeding, including legislating the International Code of Marketing, BFHI
in the Health System, and Baby-friendly Community activities, as well as any of the
above synergistic activities.
SECTION 1.6
RESOURCES, REFERENCES AND WEBSITES
Concerning the resources, references and websites listed below, please remember – web
sites change frequently. Search for the key words ‘BFHI’, Baby-friendly, and
breastfeeding in the sites search engine, and look under Resources, Publications and
Links within the web site.
UNICEF
For more information on UNICEF’s work on infant and young child feeding support of
country efforts to implement the targets of the Innocenti Declaration and the Global
Strategy for Infant and Young Child Feeding, or on the Baby-friendly Hospital Initiative
as a whole, and to download copies as materials are updated, please refer to
http://www.unicef.org/nutrition/index_breastfeeding.html
WHO
Nutrition for Health and Development (NHD)
http://www.who.int/nut/publications.htm#inf
Global Strategy for Infant and Young Child Feeding. World Health Assembly May 2002. Full text
in PDF in English, Arabic, Chinese, French, Russian, Spanish.
World Health Organization and Wellstart International. The Baby-friendly Hospital Initiative.
Monitoring and reassessment: Tools to sustain progress. Geneva, World Health
Organization, 1999 (Document WHO/NHD/99.2).
Department of Child and Adolescent Health (CAH)

http://www.who.int/child-adolescent-health/NUTRITION/infant.htm
Implementing the Global Strategy for Infant and Young Child Feeding: Report of a technical
meeting
Breastfeeding and maternal medication: Recommendations for drugs in the eleventh WHO
model list of essential drugs
Complementary feeding: Report of the Global Consultation, and Summary of Guiding
Principles for complementary feeding of the breastfed child
Guiding principles for complementary feeding of the breastfed child WHO, PAHO
Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life
The optimal duration of exclusive breastfeeding, Report of an expert consultation
WHO/FCH/CAH/01.24
The optimal duration of exclusive breastfeeding, A systematic review WHO/FCH/CAH/01.23
Statement on the effect of breastfeeding on mortality of HIV-infected women
Evidence for the Ten Steps to Successful Breastfeeding WHO/CHD/98.9 English, French and
Spanish
Complementary feeding of young children in developing countries: A review of current
scientific knowledge WHO/NUT/98.1
Health aspects of maternity leave and maternity protection
Breastfeeding and maternal tuberculosis UPDATE, N 23 February 1998
Breastfeeding and the use of water and teas UPDATE, N 9 November 1997
Not enough milk UPDATE, N 21 March 1996
Hepatitis B and breastfeeding UPDATE, N 22 November 1996
Section 1.6: Resources, References and Websites 56
Breastfeeding counselling: A training course UPDATE, N 14 August 1994

HIV and Infant Feeding: Framework for Priority Action English and French versions
HIV transmission through breastfeeding. A review of available evidence ISBN 92 4 159271 4
HIV and Infant Feeding. Guidelines for decision-makers ISBN 92 4 159122 6
HIV and Infant Feeding. A guide for health-care managers and supervisors ISBN 92 4 159123 4
Mastitis. Causes and management WHO/FCH/CAH/00.13
HIV and infant feeding counselling: A training course WHO/FCH/CAH/00.2-4
English and Spanish versions
Relactation. A review of experience and recommendations for practice WHO/CHS/CAH/98.14
Persistent diarrhoea and breastfeeding WHO/CHD/97.8
Hypoglycemia of the newborn. Review of the literature WHO/CHD/97.1
Breastfeeding counselling: A training course WHO/CDR/93.3-5
Department of Reproductive Health and Research (RHR),

Email: [email protected]
www.who.int/reproductive-health/pages_resources/listing_maternal_newborn.en.html
Pregnancy, childbirth, postpartum and newborn care - a guide for essential practice. (2003)
Kangaroo Mother Care - a practical guide (2003)
OTHER ORGANIZATIONS: POLICIES, BACKGROUND AND PROTOCOLS

Academy for Breastfeeding Medicine, International: The Academy of Breastfeeding
Medicine is a worldwide organization of physicians dedicated to the promotion,
protection and support of breastfeeding and human lactation: http://www.bfmed.org
ABM Executive Office
191 Clarksville Road
Princeton Junction, NJ 08550
Toll free: 1 877-836-9947 ext. 25 Fax: 1 609-799-7032
Local/International: 1 609-799-6327
Email: [email protected] http://www.bfmed.org
Selected Protocols Available:
Hypoglycemia (English) Hypoglykämie (German) Hipoglucemia (Spanish)
Going Home/Discharge (English) Alta (Spanish)
Supplementation (English) Alimentación suplementaria (Spanish)
Mastitis (English) Mastitis (Spanish)
Peripartum BF Management (English) Manejo en el Periparto de la Lactancia (Spanish)
Cosleeping and BF
Model Hospital Policy
Human Milk Storage Information
Galactogogues
Breastfeeding the Near-term Infant
Neonatal Ankyloglossia
Transitioning from the NICU to Home
Australian National Breastfeeding Strategy,

http://www.health.gov.au/pubhlth/strateg/brfeed/
Coalition for Improving Maternity Services (CIMS),
Coalition for Improving Maternity Services (CIMS)
National Office, PO Box 2346, Ponte Vedra Beach, FL 32004 USA
www.motherfriendly.org [email protected]
Emergency Nutrition Network (ENN): aims to improve the effectiveness of

emergency food and nutrition interventions by providing a forum for the exchange of
field level experiences between staff working in the food and nutrition sector in
emergencies strengthening institutional memory amongst humanitarian aid agencies
working in this sector helping field staff keep abreast of current research and evaluation
findings relevant to their work better informing academics and researchers of current
field level experiences, priorities and constraints thereby leading to more appropriate
applied research agendas
Unit 13, Standingford House, Cave Street, Oxford, OX4 1BA, UK
Tel: +44 (0)1865 722886 Fax: 44 (0)1865 722886
Email: [email protected] http://www.ennonline.net/
IBFAN: the International Baby-Food Action Network - consists of public interest
groups working around the world to reduce infant and young child morbidity and
mortality. IBFAN aims to improve the health and well being of babies and young
children, their mothers and their families through the protection, promotion and support
of breastfeeding and optimal infant feeding practices.
http://www.ibfan.org/
Protecting Infant Health: A Health Workers’ Guide to the International Code of Marketing of
Breastmilk Substitutes (available in a variety of languages)
The Code Handbook: A Guide to Implementing the International Code of Marketing of
Breastmilk Substitutes
International Lactation Consultant Association (ILCA), http://www.ilca.org

International Board of Lactation Consultant Examiners (IBLCE),
http://www.iblce.org/
La Leche League International (LLLI), http://www.lalecheleague.org/
LINKAGES: a USAID-funded program providing technical information, assistance,
and training to organizations on breastfeeding, related complementary feeding and
maternal dietary practices, and the lactational amenorrhea method - a modern
postpartum method of contraception for women who breastfeed, website includes
publications to download: http://www.linkagesproject.org/
Exclusive Breastfeeding: The Only Water Source Young Infants Need - Frequently Asked
Questions: Discusses the nutritional and health consequences of giving infants water during the
first six months, and the role of breastfeeding in meeting an infant’s water requirements.
Languages Available: English (2004), French (2004), Spanish, Portuguese (2002)
Community-Based Strategies for Breastfeeding Promotion and Support in Developing
Countries: WHO and LINKAGES examine the role of communities and community-based
resource persons in providing support to mothers who breastfeed. This report is based on a
review of the literature and an analysis of three projects; it assesses the impact of interventions,
the mechanisms through which behaviours can be changed, and the factors that are necessary to
maximize and sustain the benefits of interventions. Author(s): A. Morrow, WHO Languages
Available: English (2004)
Infant Feeding Options in the Context of HIV: This document identifies the specific behaviours
required of a mother or caregiver to act upon the infant feeding recommendations and informed
choice policy of WHO, UNICEF, UNAIDS, and UNFPA. Languages Available: English (2004)
Mother-to-Mother Support for Breastfeeding- Frequently Asked Questions: Focuses on a support
group method where experienced breastfeeding mothers model optimal breastfeeding practices,
share information and experiences, and offer support to other women in an atmosphere of trust
and respect. Languages Available: English (2004), French (1999), Spanish (1999)
World Alliance for Breastfeeding Action (WABA), website includes publications to

download: http://www.waba.org.my/
Wellstart, International: Wellstart International's mission is to advance the
knowledge, skills, and ability of health care providers regarding the promotion,
protection, and support of optimal infant and maternal health and nutrition from
conception through the completion of weaning.
P.O. Box 80877 San Diego, CA 92138-0877
Phone: 619-295-5192 Fax: 619-574-8159
E-mail: [email protected] www.wellstart.org
OTHER SOURCES
Kangaroo Mother Care This web site has downloadable resources on the research
supporting Kangaroo Mother Care and experiences of implementing this practice.
http://www.kangaroomothercare.com
EU Project on Promotion of Breastfeeding in Europe, Protection, promotion and
support of breastfeeding in Europe: a blueprint for action. European Commission,
Directorate Public Health and Risk Assessment, Luxembourg, 2004.
http://europa.eu.int/comm/health/ph_projects/2002/promotion/promotion_2002_18_en.htm
JOURNAL REFERENCE SITES
Medline--National Library of Medicine http://www.ncbi.nlm.nih.gov/entrez/query.fcgi
Google are developing a free web searcher that searches research journals on open
access. http://scholar.google.com/
The publishers of most of the journals have a searchable web site where the abstract and
sometimes the full text of an article can be viewed or downloaded.
BFHI Committees willing to be listed in this edition:
Australia http://www.acmi.org.au/
Canada http://www.breastfeedingcanada.ca/
Ireland http://www.ihph.ie/babyfriendlyinitiative/
Netherlands http://www.zvb.borstvoeding.nl
Switzerland www.allaiter.ch
United Kingdom http://www.babyfriendly.org.uk/
USA www.babyfriendlyusa.org
There are more than 50 additional Committees and National Authorities that may be
identified by a local UNICEF or WHO office.
If your committee would like to be listed, please let UNICEF know, by email:
Subject line: Attn. Nutrition Section at: [email protected]
ADDITIONAL RESOURCES WILL BE MADE AVAILABLE

AS RESOURCES PERMIT.
For further information please contact:
Department of Nutrition for Health and Development (NHD)

World Health Organization
20 Avenue Appia
1211 Geneva 27
Switzerland
Tel + 41 22 791 33 26
Fax + 41 22 791 41 59
Website: http://www.who.int/nutrition
UNICEF
Nutrition Section - Programme Division
3 United Nations Plaza
New York, New York 10017, United States of America
Tel + 1 212 326 7000
Website: http://www.unicef.org/nutrition/
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BABY-FRIENDLY HOSPITAL INITIATIVE:

Revised, Updated and Expanded for

Preliminary Version for Country Implementation

Produced by the World Health Organization and UNICEF.

1.Breast feeding. 2.Hospital administration. 3.Maternal welfare. 4.Program evaluation.

ISBN 92 4 159501 9 (NLM classification: WQ 27.1)

Cover image “Maternity”, 1963,

© United Nations Children’s Fund December 2005

These multi-country and multi-organizational contributions were invaluable in helping to fashion

The current BFHI package1 includes:

Section 1: Background and Implementation, which provides guidance on the revised

Section 5: External Assessment and Reassessment2, which provides guidelines and

1.2 Hospital Level Implementation

1.3 The Global Criteria for the BFHI

1.4 Compliance with the International Code of Marketing of

1.5 Baby-friendly Expansion and Integration Possibilities

1.6 Resources, References and Websites 55

Background Rationale for Revisions

This implementation plan encourages all countries to revitalize action programmes

TEN STEPS TO SUCCESSFUL BREASTFEEDING

The process of becoming a baby-friendly hospital is outlined in Section 1.2. In brief, it

Five Steps in Implementing BFHI at the Country Level

- 1B. What is the role of the National Authority in relation to BFHI?

- 3A. Who selects the BFHI Coordination Group?

- 3B. What are the roles of this Group?

If facilities fail to be in compliance when re-assessed, they will be allowed one

Five Steps in Implementing BFHI at the Country Level:

National Criteria for Baby-friendly Community Designation

Section 1.1 - Annex 1:

Suggested Questions for a Rapid Baseline Country Assessment

Where there is already an active National Authority or BFHI programme, ensure

4. What training courses or curricula exist to train:

9. Do you know of any government entities involved in supporting and/or monitoring:

Section 1.1 - Annex 2:

Excerpts from recent WHO, UNICEF, or other global publications

From UNICEF Press Release, August 2004

From UNICEF Executive Director Ann M Veneman for World Breastfeeding

From “Investing in Development: A Practical Plan to Achieve the Millennium

From World Health Assembly 2004:

Section 1.1 - Annex 3:

Breastfeeding significantly reduces early childhood

Breastfeeding and adequate complementary feeding

Breastfeeding is the great equalizer, giving every child

By reducing infectious disease incidence and severity,

The activities called for in the Global Strategy include

Based on extrapolation from the published literature

Breastfeeding is associated with decreased milk industry

The Global Strategy for Infant and Young Child

HIV and Infant Feeding

12 Prevention of mother-to-child-transmission (of HIV/AIDS).

The Baby-friendly Hospital Designation Process

THE BABY-FRIENDLY HOSPITAL DESIGNATION PROCESS

Facility invites external assessors to conduct an

Criteria for the 10 Steps, the Code, and optional components

STEP 1. Have a written breastfeeding policy that is routinely communicated to

Global Criteria - Step One

Global Criteria - Step Two

Global Criteria - Step Three

STEP 4. Help mothers initiate breastfeeding within a half-hour of birth.