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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.


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.”

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.

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.
  2. 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.
  3. 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.” 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 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, which includes all types of quantitative research, for example observational studies, and is not limited to RCTs.
  4. 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.
  5. 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 (, UNICEF ( 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 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 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.



Trish MacEnroe
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
International Lactation Consultant Association (ILCA)

Ann Calandro
La Leche League International (LLLI)

Felicity Savage
World Alliance for Breastfeeding Action


Additional translations of this communication are available in French, Italian, Portuguese, and Spanish.

Editor’s Note: The International Lactation Consultant Association would like to applaud the important advocacy efforts of our representatives, Kathleen Marinelli, Joan Dodgson, and Linda Smith, who have worked within this collaborative.

2 Responses to Discussions with the WHO and UNICEF Regarding the Future of the Global Baby-Friendly Hospital Initiative

  1. Doraine Bailey, MA, IBCLC 20 March 2018 at 14:58 #

    Can I get permission to forward this to the members and email listserv for the Kentuckiana Lactation Improvement Coalition, to urge their response as well? Will it be posted to the ILCA FB page for easy sharing?

    • lactationmatters 20 March 2018 at 16:57 #

      You can certainly share this link with those in your networks. It has been posted to our ILCA Facebook page as well.

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