What It Takes to Scale Up Breastfeeding Support: Country Experiences with the National Responsibilities for the Baby-Friendly Hospital Initiative

By Alyssa Klein, USAID Advancing Nutrition Technical Advisor

In 2018, the World Health Organization and UNICEF issued new implementation guidance for the Baby-Friendly Hospital Initiative (BFHI), a global effort focused on establishing and promoting practices that safeguard, encourage, and sustain breastfeeding. They updated the Ten Steps to Successful Breastfeeding (Ten Steps) and provide guidance on new strategies for countries to improve BFHI implementation and breastfeeding practices.?

The guidance moved away from external baby-friendly facility designation towards institutionalizing the Ten Steps into national standards of care. To gain political will for universal coverage and sustainability for breastfeeding protection and promotion, they also recommended nine key national responsibilities.

As countries adapt BFHI programs to this paradigm shift, documenting, and sharing experiences are critical, yet government efforts to secure political will and commitment to breastfeeding have not been well demonstrated or documented in low- and middle-income countries.

Throughout the life of the project, USAID Advancing Nutrition has worked to support and promote breastfeeding around the world. As part of that work, we conducted a two-country case study in the Kyrgyz Republic and Malawi to document achievements in institutionalizing BFHI, specifically looking at how they are addressing some of the national responsibilities. In the Kyrgyz Republic, we looked at the fifth responsibility—development and implementation of incentives and/or sanctions. In Malawi, we looked at the sixth responsibility—providing technical assistance. In both countries we explored the three sustainability responsibilities (national monitoring [7], communication and advocacy [8], and financing [9]), as well as the third responsibility—health professional competency building. The case study includes reviews of policy and programmatic documents in both countries, as well as key informant interviews, 38 in the Kyrgyz Republic and 47 in Malawi, with policy makers, administrators, managers, service providers, and expert stakeholders.

Key findings include—?

• Both countries have strong structures for leadership, coordination, policies, and professional standards with the potential to scale up, institutionalize, and sustain the Ten Steps. However, the 2019 coronavirus disease pandemic further constrained financial and human resources.
• National policies and national and subnational plans need to be effectively communicated throughout the health system so that all levels (national, subnational, and facility) are implementing BFHI in compliance with the latest policies and plans. And coordination across sectors (health, education, finance, and planning, among others) is important to institutionalizing the Ten Steps using all of the national responsibilities.??
• Technical assistance is commonly provided for professional competency building, but could support hospital practices, procedures, and management.
• Understanding the motivations of providers and health systems to implement the Ten Steps and monitoring key indicators are important for incentives and sanctions to be effective.
• Advocacy for multi-sectoral engagement around the Ten Steps is needed to sustain national and local commitment and funding for institutionalizing BFHI.
• In both countries, there are gaps in funding and monitoring competency building for breastfeeding counseling and support in preservice and in-service.

Read the two articles published in the Journal of Maternal and Child Nutrition to further explore case study findings. One article focuses on the two-country analysis of the revised BFHI responsibilities, and another, centers on building health professional competency for BFHI (the third responsibility) in the Kyrgyz Republic.

In addition to these publications, we also created a series of short videos that provide background on incentives and sanctions for BFHI, and share country experiences and learning around using incentives and sanctions for institutionalizing the Ten Steps for Successful Breastfeeding. The videos include experts from WHO, UNICEF, USAID Advancing Nutrition, and country examples from the Kyrgyz Republic, Vietnam, Brazil, and Rwanda. Check out the video series on the USAID Advancing Nutrition website.