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Protecting, promoting and supporting breastfeeding

Virtually all of the community-based programmes that have resulted in reductions in malnutrition have focused on improvements in infant feeding, especially the protection, promotion and support of breastfeeding.

While community-based support for breastfeeding is a major achievement, even the efforts of communities well aware of the central importance of breastfeeding can be foiled by larger economic and institutional pressures.

The blitz of inappropriate advertising and promotion by manufacturers of breastmilk substitutes -- mostly infant formula -- has been a central challenge in the fight to protect and promote breastfeeding. While infant formula is an important product for the minority of children who for some reason are not, or cannot be, breastfed, sales and promotional activities around it have sometimes been based on untrue claims of its value compared with that of breastmilk.

Promotional activities, such as providing free or subsidized supplies of infant formula, bottles and teats in maternity wards, have also undermined the best intentions and the confidence of new mothers to breastfeed.

In 1981, the World Health As sembly, which consists of the health ministers of almost all countries, responded vigorously to inappropriate promotional efforts of the infant-food industry by adopting the International Code of Marketing of Breastmilk Substitutes, drafted by WHO, UNICEF, NGOs and representatives of the infant food industry.2

The Code establishes minimum standards to regulate marketing practices by setting out the responsibilities of companies, health workers, governments and others and provides standards for the labelling of breastmilk substitutes. Among its provisions are that health facilities must never be involved in the promotion of breastmilk substitutes and that free samples should not be provided to pregnant women or new mothers.

Progress has been relatively slow in translating the Code's minimum provisions into national laws. As of September 1997, only 17 countries had approved laws that put them into full compliance with the Code. Training and development of model legislation are now accelerating action in this area. Support from the Government of Sweden has enabled UNICEF to provide greater technical assistance on Code implementation and other legal aspects of breastfeeding support.

A recent report, Cracking the Code, by the Interagency Group on Breastfeeding Monitoring, based in the United Kingdom, highlights the work that remains to be done. It documents widespread violations of the Code by multinational companies in four countries: Bangladesh, Poland, South Africa and Thailand.

The Baby-Friendly Hospital Initiative

As a complement to community-based efforts to protect, promote and support breastfeeding and to promulgate the Code, UNICEF and WHO in 1991 began an intensive effort to trans form practices in maternity hospitals.

The Baby-Friendly Hospital Ini tiative (BFHI), as the effort is called, brought a structured programme to breastfeeding support and, in just six years, has helped transform over 12,700 hospitals in 114 countries into centres of support for good infant feeding. These baby-friendly hospitals are havens of protection for breastfeeding, where women and children are not subject to advertising and promotional activities for infant formula or feeding bottles, and where they can receive effective and well-informed help for a sound start to breastfeeding.

BFHI has a simple but thorough approach. Through a WHO-UNICEF training programme that has been translated into the official languages of the United Nations and into many others, the professional staffs of maternity hospitals are trained in lactation management and support. Staff members, along with the directors or managers of their health facility, make a commitment to fulfil the initiative's 'Ten steps to successful breastfeeding. These include pledg ing to ensure that women and newborns can remain together all the time and that women must be free to begin breastfeeding promptly after birth and to continue exclusive breastfeeding on demand during their hospital stay.

Step 10 calls for setting up breastfeeding support groups that new mothers can rely on. Hospitals can be awarded 'baby-friendly' status only when specially trained independent evaluators have ensured that all 10 steps are met.

It is hard to overestimate the success of BFHI. More than a million people are working to implement its programme, and the overall pace of hospital certifications has not slowed. Patterns of declining breastfeeding, particularly in urban areas, have been reversed in country after country following BFHI implementation (Panel 13).

Photo: Keeping babies close to their mothers is fundamental in a baby-friendly hospital. A mother and child in Brazil 'room in'.

The success of the initiative can also be measured in the health of young children. In Panama, the Min istry of Health reported a 58 per cent reduction in respiratory infections and a 15 per cent decline in diarrhoea in infants in just one year in a single baby-friendly facility, the Amador Guerrero Hospital. In north-eastern Brazil, Acari Hospital credits BFHI with dramatic cost savings from decreased hospitalization of infants and reduced case fatality among them. In the first two years of BFHI implementation at the Central Hospital of Libreville in Gabon, it was estimated that there was a 15 per cent reduction in cases of neonatal diarrhoea, a 14 per cent reduction in dehydration and an 8 per cent reduction in mortality.

Successes outside the developing world

BFHI is not just for non--industrialized countries.

An evaluation in the Republic of Moldova, once part of the former Soviet Union near the Romanian border, showed an average reduction in all neonatal infections in four baby-friendly hospitals from about 18 per cent to 7.5 per cent in two years of the programme. The neonatal infection rate in the hospital that had been certified as baby-friendly the longest dropped from 23 per cent to 3.4 per cent. Rates of breastfeeding initiation in the country rose appreciably, and rates of continued breastfeeding at 6 and 12 months were significantly higher over the period of implementation of the programme.

Similar results are being reported from Asia and Latin America, and some countries are in the process of conducting extensive evaluations of BFHI's impact. In the United States, there is an active BFHI programme, and 11 hospitals have been declared baby-friendly.

BFHI was conceived by a small group of experts with vision and leadership and was tested, modified and then introduced globally. But it could not have succeeded without the engagement of local institutions and communities. Local NGOs have played a significant role in the promotion and sustenance of BFHI in many countries. And an international NGO, the World Alliance for Breastfeeding Ac tion (WABA), founded in 1991, has helped solidify actions in support of the initiative and breastfeeding beyond the hospital through its work in networking, information sharing and advocacy.

National breastfeeding committees, though often established prior to BFHI, were energized by the initiative's concrete achievements. Paediatric and obstetric professional as so ciations have endorsed the programme and have been educated by it.

BFHI has also helped establish breastfeeding firmly on the political agenda. The challenge for the future is to use the political energy behind BFHI to ensure that breastfeeding promotion and support extend beyond hospital walls and that breastfeeding support groups become a constant priority for communities and governments.

Complementing breastfeeding

Good infant feeding includes not only support for breastfeeding but also ensuring good complementary feeding practices for children more than six months old whose nutritional needs can no longer be fully met by breastfeeding, though sustained breastfeeding well into the second year of life remains important (Panel 14).

The CSD Programme in Tanzania brought about a number of significant improvements in household-level prep aration of good-quality complementary foods, including porridges with reduced viscosity designed to increase consumption by young children.

Until recently, however, there has not been good scientific consensus on a number of questions related to the additional food needs of older breastfed children. WHO and UNICEF recently brought together a group of internationally renowned scientists and programme practitioners familiar with these problems, and a consensus report will soon be published that will offer technical guidance for improving complementary feeding.

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