Asia Pacific J Clin Nutr (1992) 1, 107-111

The baby-friendly hospital initiative

Petri V.E. Volmanen, MD, Ian Darnton-Hill, MBBS, MPH and Bituin Gonzales, BSSW

WHO Regional Office for the Western Pacific, P.O. Box 2932,1099 Manila, Philippines (PVEV, ID-H), UNICEF, 106 NEDA Building, Amorsolo Street, Makati, Metro Manila, Philippines (BG).

A new global 'baby-friendly hospital initiative' has been launched by UNICEF and WHO. Its central elements are hospital practices that are known to protect, promote and support breast-feeding. The health benefits of breast-feeding have been shown to be more extensive than previously believed. The new initiative is needed because the 'code of marketing of breast-milk substitutes' alone has not had enough impact on infant-feeding practices. Also, contrary to expectations in most parts of the world, the health services have generally been unable to help mothers to breast-feed.

The 'baby-friendly hospital initiative' employs four basic interventions that have been shown to be effective in increasing breast-feeding: counselling of the mother, early initiation of breast-feeding, rooming-in and the establishment of support groups for mothers. The main strategy for overcoming institutional constraints to breast-feeding is to train the maternity health care providers. Also, administrative procedures and public information campaigns may be needed.

Figure 1. Factors affecting breast-feeding practices.

The baby-friendly hospital initiative

The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) have launched a new initiative aimed at promoting breast-feeding through the creation of 'baby-friendly' hospitals. The plan was adopted at a meeting of paediatricians, obstetricians, community health workers, and members of nongovernmental organizations in Ankara, Turkey, on 28 June 1991. The initiative aims to encourage hospitals and maternity services to adopt practices known to promote the health and well-being of babies being born in hospitals and the health of the mothers. It includes the promotion of breast-feeding and complements existing strategies as illustrated in Figure 1.

This communication summarizes some of the large and growing body of scientific evidence that formed the basis for the initiative to make hospitals in the region 'baby-friendly'. The need for this initiative and the specific interventions used are discussed.

The milk code

The 'international code of marketing of breast-milk substitutes' ¹, also known as the 'milk code', has been one of the main strategies in the promotion of breast-feeding.

However, only a minority of the WHO's member states have adopted the Milk Code as legislation since it was introduced in 1981. In countries where it has been adopted, a number of difficulties have arisen, as recently revealed by WHO country case studies on milk code implementation².

Cumulative evidence of the advantages of breast-feeding

The advantages of breast-milk over its substitutes have been repeatedly shown in studies demonstrating that, among other things, breast-feeding provides protection against morbidity and mortality from diarrhoeal diseases^3-10. Recent studies have shown that it also protects infants against respiratory illnesses, such as pneumonia and otitis media^11-14. Reduced risk of bacteraemia and meningitis^15,16, as well as specific nutritional deficiencies^17,18, and sudden infant death syndrome¹⁹ have also been reported. Recent studies have indicated a consistent association between bottle-feeding and immune system disorders^16,20,21. Diseases such as Crohn's disease, coeliac disease, insulin-dependent diabetes, and Iymphoma belong to this group. Reduced mortality among the breast-fed population in contrast to the artificially fed has also been reported^22-26.

For premature babies artificial feeding entails an increased risk of necrotizing enterocolitis²⁷.

The health benefits of breast-feeding to the mother must also be mentioned, such as reduced risk of breast and ovarian cancers^28-31, and probable reduced postpartum bleeding.

Breast-feeding also has a marked impact on fertility³². Recent WHO collaborating studies have shown that the so-called lactation amenorrhoea method as a public health means of contraception is as effective as any other known method³³. The child-spacing potential of continued breast-feeding has a special importance in countries where birth spacing methods are not widely available.

Role of health services

Contrary to expectations, it has been shown that health services in many parts of the world are not promoting breast-feeding effectively. In a WHO collaborative study on contemporary patterns of breast-feeding in 1981, a negative correlation between attending prenatal clinics and prevalence and duration of breast-feeding was noted globally. In countries where the comparison between home and hospital deliveries could be made, there was a negative correlation between breast-feeding and giving birth in an institution³⁴.

From this we cannot, of course, necessarily draw the conclusion that health services undermine breast-feeding. However, it does appear that health services do not sufficiently promote breast-feeding by encouraging mothers to choose to breast-feed, rather than to yield to the anxiety and problems of initiating breast-feeding that sometimes occur, especially with the first child.

Various more recent studies have also shown that the knowledge, attitudes and skills of health workers in most parts of the world are insufficient in this regard^35-40.

The health and economic advantages of changing hospital practices to rooming-in have been dramatically shown in the cases of Baguio Hospital and the Jose Fabella Memorial Hospital in the Philippines, examples in but one country^41,42.

Tools for change

These findings, and the fact that breast-feeding is not increasing in the way that is needed to reach national health goals, indicate the need for new approaches, especially in the field of health services.

A 'baby-friendly' hospital employs four basic interventions: counselling of the mother, early initiation of breast-feeding, rooming-in and the establishment of support groups for mothers.

An observational study in Israel reported a significantly longer period of breast-feeding among mothers who were given appropriate advice by their obstetricians⁴³. Another study, in the form of a clinical trial, demonstrated a higher breast-feeding rate in mothers receiving both in-hospital and home support by a lactation nurse⁴⁴. In a study carried out in Indonesia, the need for lactation counselling of mothers was shown by assessing the awareness of mothers in maternity clinics. For example, hardly any of them understood the importance of frequent suckling in promoting milk production⁴⁵.

Several clinical trials have studied the influence of early maternal-infant contact on breast-feeding duration. A positive correlation has been reported in studies made in England, Jamaica, Sweden and the United States^46-48. A prospective study on breast-feeding practices in a poor urban cohort in Brazil also showed the importance of the type and timing of the first feed for the baby⁴⁹. An analysis of nine studies on the effects of hospital practices on breast-feeding duration revealed a significant correlation (P < 0.05) between early contact and duration of breast-feeding⁵⁰. However, in many traditional societies, where breast-feeding prevalence remains high, the beginning of breast-feeding is usually delayed. It has therefore been concluded that early initiation should be emphasized when traditional patterns of nursing (ie on-demand nursing, especially during the night) are not followed⁵¹. Also, unnecessary hospital routines such as gastric emptying of all newborn infants can interfere with successful early mother-infant contact⁵².

Several observational studies have also reported significant links between rooming-in and longer duration of breast-feeding⁴⁸. One study compared the duration of breast-feeding of mothers whose infants stayed with them with that of those who were separated for a short period of time (mean 3.3 days) during the first week after delivery. A significant difference (P<0.001) was found in the three-month breast-feeding frequencies of 72% in the 'roomed-in' group as compared with 37% in the separated group⁵³.

The support of lay groups, such as the La Leche League, Nursing Mothers Association etc has been reported to have a positive impact on the promotion of breast-feeding⁵⁴. Follow-up support in the form of hospital contact with the mothers after they return home was also found effective in an analysis of nine studies on the effect of hospital practices on breast-feeding duration⁵⁰. The main strategy for overcoming institutional constraints to breast-feeding is to train the maternity health care providers, convincing them of the superiority of breast-feeding. This can be done by providing persuasive and scientifically sound information⁵⁵. Administrative procedures ranging from hospital guidelines to national rooming-in legislation are also needed. Finally, public information campaigns will increase awareness and consumer demand for this kind of support.

Footnote: This article has been exceptionally approved to be published simultaneously in several medical journals in the Western Pacific region of the World Health Organization in order to reach as many of the target group of nutritionists, obstetricians, paediatricians and hospital administrators working in hospitals and maternity services as possible.

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Copyright © 1996 [Asia Pacific Journal of Clinical Nutrition]. All rights reserved.
Revised: January 19, 1999 .

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