PHM-Exch> Discussions with the WHO and UNICEF Regarding the Future of the Global Baby-Friendly Hospital Initiative

[Claudio Schuftan]

From: World Alliance for Breastfeeding Action (WABA) <waba at waba.org.my>


*Discussions with the WHO and UNICEF Regarding the Future of the Global
Baby-Friendly Hospital Initiative*
Dear Colleagues,

We are writing as a collaboration of five organizations that formed to
provide unified feedback to the World Health Organization (WHO) and the
United Nations Children's Fund (UNICEF) in the wake of proposed changes to
the Global Baby-Friendly Hospital Initiative (BFHI).

We want to make sure all stakeholders in our networks are informed about
the changes WHO and UNICEF have proposed, the concerns we have expressed,
and the modifications to the proposals we have recommended.  We are also
pleased to share with you that WHO and UNICEF have already made some of our
recommended changes.

*Background *

On October 11 of last year the WHO and UNICEF released their draft revised
BFHI Operational Guidance titled “*Protection, promotion, and support of
breastfeeding in facilities providing maternity and newborn services: The
revised Baby-friendly Hospital Initiative 2017*
<https://waba.us8.list-manage.com/track/click?u=9c4737de875c6fa12b87991e8&id=0198c115e1&e=858833e631>
.”

This document was open for public comment for two weeks and more than 300
individuals and organizations provided feedback during this brief period.
As a result of extensive concerns expressed by many stakeholders about the
magnitude of the changes proposed and the extremely short timeframe for
review and feedback, the WHO and UNICEF decided to delay publication of the
proposed BFHI Operational Guidance until there could be further
consultations with our five global breastfeeding organizations. Our
organizations formed a collaborative, developed a list of 10 key concerns,
and have been working closely together since then to provide consolidated
and constructive feedback to the WHO and UNICEF on the proposed changes.
We are pleased to report that there has been some progress on addressing
our concerns.

*Ongoing Areas of Concern*

Our collaboration agrees with WHO and UNICEF that the BFHI should be
updated, revitalized and include broad and robust components to more
effectively guide safe implementation of practices.   While we are not
included in all discussions underway, our latest information suggests that
some critical issues remain:


   1. The proposal still includes the development of individual national
   criteria.  It now includes global standards and recommends that the
   national criteria be based on them.   While this adopts part of our
   recommendation (maintaining strong global standards), we still believe this
   approach will allow for wide variation of practices and inconsistent
   standards throughout the world, undermining global indicators. Global
   standards are the foundation of the BFHI and they are essential to
   monitoring the global effort to improve breastfeeding rates.  To achieve
   global standards of practice, there is a need for standardized, model
   training courses, many of which already exist, and may need only minor
   adaptation for the revised BFHI.



   1. The proposal includes support for BFHI designation as a key strategy
   for maternity care practice improvement, however it continues to be
   optional.  We believe optional designation weakens one of the most
   effective strategies used to achieve sustainable improvements in the
   quality of maternity care and breastfeeding rates, as evidenced by research
   and its success in many countries.



   1. Recent communication from WHO and UNICEF indicates agreement that the
   order, number and subject matter of each of the original Ten Steps to
   Successful Breastfeeding will be retained.  There will be some
   modifications to the language and interpretation of the Steps.  Most of the
   changes are improvements and reflect current evidence.  We support this
   action as it enables the Steps to evolve with the evidence.  However, the
   proposed new language for Step 9 remains a concern.



   1. The basis for the proposed changes to the Ten Steps is a 136-page
   review of the evidence released by the WHO on November 3 of last year –
   after the public comment period for the draft Operational Guidance closed –
   in a similarly-named document, “*Protecting, promoting and supporting
   breastfeeding in facilities providing maternity and newborn services*
   <https://waba.us8.list-manage.com/track/click?u=9c4737de875c6fa12b87991e8&id=3b63f5e0b3&e=858833e631>.”
   While each of the Steps was reviewed individually, the review did not
   address the efficacy of the BFHI program as a whole, which is commonly a
   key component of program evaluation. Since the *GRADE*
   <https://waba.us8.list-manage.com/track/click?u=9c4737de875c6fa12b87991e8&id=5d38be7c34&e=858833e631>
protocol
   used to create this document only considers randomized controlled trials
   (RCTs) as appropriate evidence, a significant body of evidence was not
   examined.  This does not equate to lack of or negative evidence. This led
   initially to the proposed elimination of Step 9, which has now been
   reinstated, though it does not yet caution against risks of using bottles
   and pacifiers. While the WHO process for evaluating the evidence on
   specific topics may have been rigorous and appropriate for addressing
   narrowly defined quantifiable questions most appropriate for medically
   related topics, it was not the most appropriate method for examining the
   evidence related to the socio-cultural and ethical complexities of the
   BFHI.   This method failed to portray the reality that those working and
   researching in this field have experienced over the past 30 years.  It
   appears that other types of protocols are utilized by the WHO, such as for
   the newly released *Intrapartum Care for Positive Childbirth Experience*
   <https://waba.us8.list-manage.com/track/click?u=9c4737de875c6fa12b87991e8&id=deb231c29f&e=858833e631>,
   which includes all types of quantitative research,  for example
   observational studies, and is not limited to RCTs.



   1. The proposed changes are likely to soften and disrupt ongoing
   productive and beneficial BFHI work occurring in all corners of the world.


*What We Have Done*

Our collaborative has sent numerous letters and documents to the WHO and
UNICEF and has had many discussions with representatives of these
organizations. We also sent a detailed memorandum to Member States’
Representatives to the Executive Board of the World Health Assembly (WHA)
prior to their January meeting in Geneva. Several of our members in
attendance at the meeting met face-to-face with WHA representatives, and
WHO and UNICEF leaders to express our concerns.

WHO and UNICEF, based on an evaluation of the evidence and information
submitted by the collaborative, appear to have made significant changes to
the proposed initial draft, including the retention of the order, number
and subject matter of each of the original Ten Steps. However, significant
gaps in the alignment of our thinking with WHO and UNICEF remain.

We urge the continued delay of publication of the proposed Operational
Guidance to allow time for additional conversation and improvements. The
WHO and UNICEF’s original plan was to launch the new guidelines in November
2017.  According to a recent communication, a new publication date may be
late March 2018.

*What You Can Do*

If you support a continued, comprehensive global review of these issues
focused on what’s best for mothers, babies and families, it is critical to
let WHO (*nutrition at who.int* <nutrition at who.int>), UNICEF (
*nutrition at unicef.org* <nutrition at unicef.org>) and your WHA representatives
hear your concerns immediately.  The Operational Guidance could be included
in a WHA resolution at the May 2018 meeting to be brought to the table for
agreement by Member States.  The 2017 WHA delegates list can be found *here*
<https://waba.us8.list-manage.com/track/click?u=9c4737de875c6fa12b87991e8&id=b546310c31&e=858833e631>
and
may be helpful in identifying and locating your own delegates.

You may wish to emphasize some or all of the following points and
recommendations that we continue to advocate for in our discussions:


   1. Retain global:  guidelines, criteria, streamlined monitoring tools,
   streamlined assessment tools, and scoring systems.
   2. Retain standardized model training courses, which can be used or
   adapted globally.
   3. Continue accreditation based on external assessment, inclusive of
   mother interviews, and conducted by knowledgeable individuals, as part of
   the process.
   4. Welcome the indication by WHO and UNICEF that they will maintain the
   metrics hospitals must achieve at the current 80% standard.
   5. Welcome the indication by WHO and UNICEF to retain the order, number
   and subject matter of each of the original Ten Steps.
   6. Welcome that the Code and internal monitoring is proposed to be
   incorporated into Step 1 on infant feeding policies.
   7. Advocate for revised language for the re-introduced Step 9, to
   clarify facility responsibility for minimizing the use of bottles, teats
   and pacifiers.  Include language about risks, and the advisability of using
   only when medically necessary or parents are appropriately educated.
   8. Continue safe and respectful birth practices as a component of the
   BFHI.
   9. Use empowering language throughout the Operational Guidance document.
   10. Keep the BFHI about healthy term infants. Adopt a separate set of
   standards pertaining to breastfeeding support for preterm and sick infants,
   such as the *NEO BFHI Baby-Friendly Hospital Initiative for Neonatal
   Wards*
   <https://waba.us8.list-manage.com/track/click?u=9c4737de875c6fa12b87991e8&id=ae465f17bc&e=858833e631>
which
   was initially developed by the Nordic-Quebec Working Group.
   11. Include a discussion of the ethical issues related to doing
   randomized trials on infant and young child feeding including those
   specific to breastfeeding.
   12. Incorporate a robust discussion regarding the interrelationship
   between each of the 10 Steps and how they work together as a comprehensive
   breastfeeding support program.


We appreciate the opportunity to communicate with WHO and UNICEF on this
important matter and look forward to continuing to do so in an open and
transparent manner. Together, we can strengthen the foundation that
supports breastfeeding around the world.

Thank you for your support.

Sincerely,

Trish MacEnroe
Coordinator
Baby-Friendly Hospital Initiative Network of Industrialized Nations,
Central and Eastern European Nations and Independent States (BFHI Network)

Elisabeth Sterken
Co-chair IBFAN Global Council
International Baby Food Action Network (IBFAN)

Michele Griswold
President
International Lactation Consultant Association (ILCA)

Ann Calandro
Chair
La Leche League International (LLLI)

Felicity Savage
Chairperson
World Alliance for Breastfeeding Action (WABA)
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