Guía: proteger, promover y apoyar la lactancia materna en los establecimientos que prestan servicios de maternidad y recién nacidos

Breastfeeding is the cornerstone of child survival, nutrition and development and maternal health. The World Health Organization (WHO) recommends exclusive breastfeeding for the first 6 months of life, followed by continued breastfeeding with appropriate complementary foods for up to 2 years or beyond.2 In 2012, the World Health Assembly Resolution 65.6 endorsed a Comprehensive implementation plan on maternal, infant and young child nutrition, specifying six global nutrition targets for 2025, one of which is to increase the rate of exclusive breastfeeding in the first 6 months up to at least 50%.

In order to support women and optimize the chances of breastfeeding in line with WHO’s recommendations, WHO and the United Nations Children’s Fund (UNICEF) published a joint statement in 1989 on Protecting, promoting and supporting breastfeeding: the special role of maternity services, which listed Ten Steps to Successful Breastfeeding.

The Ten Steps were re-emphasized in the Innocenti Declaration on the protection, promotion and support of breastfeeding, adopted in Florence, Italy in 1990, and the Innocenti Declaration 2005 on infant and young child feeding, published in 2005. They became part of the Baby-friendly Hospital Initiative, published in 1991, and the updated version in 2009.

The Baby-friendly Hospital Initiative provides guidance on the implementation, training, monitoring, assessment and re-assessment of the Ten Steps to Successful Breastfeeding and the International Code of Marketing of Breastmilk Substitutes, a set of recommendations to regulate the marketing of breast-milk substitutes, feeding bottles and teats adopted by the 34th World Health Assembly (WHA) in 1981, and its subsequent related WHA resolutions. The Baby-friendly Hospital Initiative has since been shown to positively impact breastfeeding outcomes as a whole, and with a dose–response relationship between the number of interventions the mother is exposed to and the likelihood of improved breastfeeding outcomes.

This guideline examines each of the practices in the Ten Steps to Successful Breastfeeding, in order to bring together evidence and considerations to inform practice. The scope of the guideline is limited to specific practices that could be implemented in facilities providing maternity and newborn services to protect, promote and support breastfeeding.

This guideline does not aim to be a comprehensive guide on all potential interventions that can protect, promote and support breastfeeding. For instance, it will not discuss breastfeeding support beyond the stay at the facility providing maternity and newborn services, such as community-based practices, peer support or support for breastfeeding in the workplace. Neither will it review the articles and provisions of the International Code of Marketing of Breast-milk Substitutes and its subsequent related WHA resolutions.

This guideline complements interventions presented in the Essential newborn care course, Kangaroo mother care: a practical guide, Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice and the Standards for improving quality of maternal and newborn care in health facilities and does not supersede or replace them.

An implementation guide that will encompass the recommendations included in this guideline, the International Code of Marketing of Breast-milk Substitutes and the Baby-friendly Hospital Initiative has been developed by WHO and UNICEF and will be published separately in Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-friendly Hospital Initiative 2017.

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GUÍA DE APLICACIÓN Protección, promoción y apoyo de la lactancia materna en los establecimientos que prestan servicios de maternidad y recién nacidos: la INICIATIVA DE HOSPITALES AMIGOS PARA BEBÉS revisada

World Health Organization and the United Nations Children’s Fund

The first few hours and days of a newborn’s life are a critical window for establishing lactation and for providing
mothers with the support they need to breastfeed successfully. Since 1991, the Baby-friendly Hospital Initiative (BFHI) has helped to motivate facilities providing maternity and newborn services worldwide to better support breastfeeding. Based on the Ten Steps to Successful Breastfeeding (the Ten Steps), the BFHI focuses on providing optimal clinical care for new mothers and their infants. There is substantial evidence that implementing the Ten Steps significantly improves breastfeeding rates.

The BFHI has been implemented in almost all countries in the world, with varying degrees of success. After more
than a quarter of a century, coverage at a global level remains low. As of 2017, only 10% of infants in the world
were born in a facility currently designated as “Baby-friendly”. Countries have found it difficult to sustain a BFHI
programme, with implementation often relying on specific individual and external resources. The programme has
characteristically been implemented as a vertical intervention focused on designating facilities that volunteer to take
part in the programme and can document their full adherence to the Ten Steps. Facilities may make changes in their
policies and procedures to obtain the designation, but these changes are not always sustainable, especially when there are no regular monitoring systems in place.

In 2015, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) began a process to
re-evaluate and reinvigorate the BFHI programme. Case-studies, key informant interviews, a global policy survey and literature reviews were conducted to better understand the status and impact of the initiative. Systematic literature reviews were commissioned to carefully examine the evidence for each of the Ten Steps. WHO convened a guideline development group to write the WHO guideline Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services and an external review group to update the guidance on country- level implementation of the BFHI. The main concepts and outline of the updated implementation guidance were discussed extensively at the BFHI Congress in October 2016, involving approximately 300 participants from over 130 countries. The draft updated guidance document was disseminated through an online consultation in October 2017 and comments from over 300 respondents were considered in the final revisions of the document.

This updated implementation guidance is intended for all those who set policy for, or offer care to, pregnant women,
families and infants: governments; national managers of maternal and child health programmes in general, and of
breastfeeding- and BFHI-related programmes in particular; and health-facility managers at different levels (facility
directors, medical directors, chiefs of maternity and neonatal wards). The document presents the first revision of the
Ten Steps since 1989. The topic of each step is unchanged, but the wording of each one has been updated in line with the evidence-based guidelines and global public health policy. The steps are subdivided into (i) the institutional procedures necessary to ensure that care is delivered consistently and ethically (critical management procedures); and (ii) standards for individual care of mothers and infants (key clinical practices). Full application of the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly Resolutions (the Code), as well as ongoing internal monitoring of adherence to the clinical practices, have been incorporated into step 1 on infant feeding policies.

The implementation guidance also recommends revisions to the national implementation of the BFHI, with an emphasis on scaling up to universal coverage and ensuring sustainability over time. The guidance focuses on integrating the programme more fully in the health-care system, to ensure that all facilities in a country implement the Ten Steps. Countries are called upon to fulfil nine key responsibilities through a national BFHI programme, including establishing or strengthening a national coordination body; integrating the Ten Steps into national policies and standards; ensuring the capacity of all health-care professionals; using external assessment to regularly evaluate adherence to the Ten Steps; incentivizing change; providing necessary technical assistance; monitoring implementation; continuously communicating and advocating; and identifying and allocating sufficient resources.

The BFHI focuses on protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. It is understood that many other interventions are needed to ensure adequate support for breastfeeding, including in antenatal care, postpartum care, communities and workplaces, as well as adequate maternity protection and Code legislation. It is critical that the BFHI programme is integrated with all other aspects of breastfeeding protection, promotion and support.

By reinvigorating the BFHI and ensuring that all facilities adhere to evidence-based recommendations on maternity
and newborn care, breastfeeding rates can be substantially increased and the health of mothers and children
dramatically improved.

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