Since the Baby-friendly Hospital Initiative (BFHI) was launched in 1991, it has served as a motivating force for maternity facilities around the world to implement policies and practices that support breastfeeding.
Change can be difficult and slow to bring about in some health facilities, but enlightened decision-makers can play a pivotal role in enabling the transformation needed. They know how to work with personnel and budgets, and how to initiate institutional change. Once higher level administrators and policy-makers have been sensitized to the importance of breastfeeding support in health facilities and the changes necessary to attain it, they will be more likely to encourage and support the continuing education needs of mid-level health workers.
This course is designed primarily for health facility decision-makers in countries where there is a commitment to breastfeeding at the central level, but progress is slow. The course is brief (about 10–12 hours in duration), practical, and addresses specific topics relevant to their needs, such as policies and procedures, costs and savings, and how to address common barriers to change. It complements other courses that provide the knowledge and skills needed by health workers who care for mothers and infants.
The course has been fully updated, with recent studies, new data and current websites added in whenever appropriate. Since HIV/AIDS poses such a challenge, HIV-related content that may be useful in all settings has been added into the session plans. In addition, two new alternative session plans have been developed that can be substituted for sessions 4 and 5 in settings with high HIV prevalence. These sessions give useful information on HIV and infant feeding and valuable guidance on how to best implement the Ten Steps in a way that best supports both HIV positive mothers and those whose status is negative or unknown.
The course website contains links to PowerPoint slides and transparencies for the various sessions. The slides (in colour) can be used with a laptop computer and LCD projector, if available. Alternatively, the transparencies (in black and white) can be printed out and copied on acetates and projected with an overhead projector. The transparencies are also reproduced as the first handout for each of the sessions, with 6 transparencies to a page.
The course comprises eight sessions that can be presented over a period of one-and-a-half to two days. Each session contributes to the final outcome: developing an action plan to implement the “Ten steps to successful breastfeeding”.
- Session 1: The national infant feeding situation enables participants to review the current infant feeding situation in their own country and addresses practices that affect breastfeeding rates.
- Session 2: Benefits of breastfeeding discusses the advantages of breastfeeding and disadvantages of artificial feeding.
- Session 3: The Baby-friendly Hospital Initiative describes the history and background of the BFHI and the related assessment process.
- Session 4: The scientific basis for the “Ten steps to successful breastfeeding” reviews the research that supports the policy recommendations.
- Session 5: Becoming Baby-friendly examines strategies for the successful conversion and management of baby friendly health facilities and provides the opportunity for discussing barriers and potential solutions.
- Session 6: Costs and savings enables participants to examine the investment in breastfeeding promotion in their own health facilities and the savings that can be realized.
- Session 7: Appraising policies and practices provides the participants an opportunity to assess their own facilities by using the “Hospital Self-Appraisal Tool for the WHO/UNICEF Baby-friendly Hospital Initiative”.
- Session 8: Developing action plans enables participants to prepare a written plan for change in their own health facilities and programmes.
Each session is organized using the same basic format. The session cover sheet provides:
- Objectives for the session.
- Teaching methods, such as lecture, discussion, small group work, and participant presentations.
- Preparation for the session, such as obtaining local breastfeeding data and reviewing research studies.
- Training materials to be used in the session, such as summaries of studies used in the session, handouts, transparencies, and PowerPoint slides. In some cases visual aids are recommended, with information on how to obtain them.
- References that will assist the faculty to prepare for the session, as well as additional reading for participants who would like more information or who would like to review the original research studies.
The session outline follows the cover sheet and is arranged in a 2-column format. The left-hand column outlines the content to be presented. The right-hand column presents trainer’s notes, which provide suggestions for teaching strategies, teaching aids, and discussion points.
The course is designed to be brief and practical. All material can be covered in about 10–12 hours, not including opening and closing sessions. There is some flexibility to the course in that sessions may be shortened or expanded, depending upon the needs of a particular group and time constraints in specific situations. Three sample agendas for the course, provided in Annex A, illustrate how it can be conducted for varying lengths of time, depending on the time decision-makers have for this activity.
- Sample agenda 1 (2 days) is the preferred version, if it is possible for all participants (top-level decision-makers, policy-makers and hospital managers) to attend a full two-day event. It allows for adequate time to explore the key topics related to implementing or revitalizing BFHI that are important for decision-makers, and provides enough time for useful exercises (such as those related to “becoming Baby-friendly”) and for developing full action plans).
- Sample agenda 2 (1 ½ days) has been adapted so that the first day would be for all the top-level decision-makers and hospital managers. The morning of the second day could be provided to all participants or, if the top-level decision-makers are “to busy” to stay, it could be attended just by the hospital managers tasked in developing BFHI action plans).
- Sample agenda 3 (1 day) has been adapted to include only a ½ day orientation for busy top-level decision-makers, along with hospital managers, and an additional afternoon session for hospital managers tasked in developing BFHI action plans. If this shortest version of the course is selected, it will be necessary for course planners to streamline each of the Sessions, choosing the content and PowerPoint slides of most relevance for their audience. If desired, this one-day version of the course can also be used with all participants staying for the entire day).
The order of the sessions can be changed if necessary to accommodate the needs of the group. In the first sample agenda, Session 1 (The national infant feeding situation) is presented first, to get participants thinking about their own situations. Some groups may need the motivation provided by Session 2 (Benefits of breastfeeding) before they can fully appreciate their own situation. The second sample agenda starts with this session, as this ordering may be best for some groups. If senior decision-makers will not stay for all of the Sessions, it is important to schedule all key informational sessions, including Session 6 (Costs and savings), before they leave. Thus, in the one-day program, Session 6 is scheduled before Session 5.
The time for opening and/or closing ceremonies is not included in the 8–12 hour course duration estimate. Remember to consider the time such ceremonies will add to the length of the course. If one or both ceremonies are important to the success of the course, the time will be well spent. Midmorning and mid-afternoon breaks are essential, as are question/discussion periods after each session; remember to plan for them. Other social events are optional.
Decide whether to have optional sessions. Some groups have suggested they would be interested in acquiring additional clinical information. One way to provide such information outside of a formal course is to offer optional viewing of videos, perhaps in the evening. Suggested videos are listed under the “Course materials” section of this course guide.
Cost issues will affect all course planning decisions and thus need to be determined early. If the decision is made to charge participants, the fee should be as low as possible while still recouping costs. Offering continuing education credits provides added incentive for participants to pay for the programme. If hospitals are charged for sending a team, consideration can be given to allowing the chief executive to come at no charge in order to further encourage high-level participation.
If course costs are a substantial problem, consideration can be given to adjusting the selection of participants and the course schedule so participants can return home at the end of the day; however, a “residential” course, with participants remaining overnight, is preferable, as the interaction and networking among facilitators and participants “after hours” is quite valuable.
It is recommended that a committee be organized to oversee course planning, implementation, and follow-up activities. Members should include those who will be involved in follow-up. The national breastfeeding or infant and young child feeding coordinator or person responsible for BFHI activities can serve as chair or facilitator.
Committee responsibilities include selection of course presenters, participants, and course site, and the planning of the schedule, protocol (ceremonies or social events), opportunities for media coverage, evaluation and follow-on activities. The committee may appoint an overall course coordinator and see that secretarial and other support services are provided. The committee should assign chairpersons and report writers for various sessions or portions of the course.
Chairpersons are responsible for serving as “master of ceremonies”, coordinating one or several session(s). They introduce the speaker(s), keep the session(s) progressing on schedule, and distribute and collect the evaluation forms.
Selection of presenters and other resource persons
Presenters for the sessions should be identified by the organizing committee. They should have appropriate credentials to be credible and convincing to the high-level participants envisioned for this course. There can be a mix of national and international faculty. It is helpful to include one or more presenters who have already taught, facilitated or attended a previous course.
The presenters can be a mix of speakers from among the facilitators who will attend the entire course and, in a few cases, outside resource persons who are scheduled just for a particular session. It is essential that the presenters be knowledgeable about specific subject areas. For example:
- Session 1 will utilize the expertise of someone with access to the data regarding the local breastfeeding situation, such as the national breastfeeding or infant and young child feeding coordinator, a policy-maker or researcher (someone involved in a KAP study, for example). This person may present part of the session in collaboration with the facilitator.
- Sessions 2 and 4 require a presenter with a strong scientific/medical background (either a course facilitator or outside resource person) who can discuss the research implications of the material. The presenter for session 4 should be familiar with the studies featured in the session (summaries are provided) and will need sufficient time to prepare. If the course is being given for settings with high HIV prevalence and the alternative Session 4 is being used, the presenter should also have expertise on HIV and infant feeding.
- Session 3 provides an opportunity for the national breastfeeding or infant and young child feeding coordinator or the WHO or UNICEF representative to describe the BFHI assessment process and to give a national status report.
- Session 5 should be led by a facilitator familiar with the issues involved in converting and managing “Baby-friendly” health facilities. If the alternative Session 5 for settings with high HIV prevalence is being used, the presenter should have expertise and, if possible, experience on implementing BFHI in these types of settings.
- Session 6 should utilize an individual knowledgeable about cost and savings involved in breastfeeding promotion at the health facility level.
- Sessions 7 and 8 should be led by a facilitator familiar with the teams attending the course and the settings from which they come and knowledgeable about program planning. The national breastfeeding or infant and young child feeding coordinator or another official who could also be assigned to follow up with the teams on implementation of their plans would be a good choice.
In the sessions requiring small group work, there should be some extra facilitators, depending upon the size of the small groups (approximately one for every five participants). Small group facilitators should have some experience with implementing the BFHI, programme planning, and working with groups.
The team of presenters needs to be arranged as far ahead as possible and their assignments made clear. Presenters should be thoroughly familiar with the curriculum guide and understand how their session(s) fit into the course as a whole.
Pre-course planning activities/session for speakers
It is essential that course sponsors and organizers meet or correspond very actively several months prior to the course. The organizing committee will need to assign teaching responsibilities and distribute session plans to faculty/facilitators several weeks before the course. Faculty will need plenty of time to become familiar with the materials and to obtain or prepare overheads or documents that describe the local situation.
Just prior to the course, a two-day session for faculty/facilitators can be held to make the final preparations needed. The agenda can be discussed and finalized, and speakers can review their responsibilities and individual session arrangements. A session-by-session discussion and/or practice session will familiarize all the faculty with the entire course so each member can see how his or her piece fits into the whole. This “walk through” will help ensure all speakers are prepared, assist in final selection of audio-visual aids and materials for audience appropriateness, and allow presenters to coordinate sessions and avoid duplication.
Selection of participants
Participants should be key decision-makers responsible for hospitals or other health facilities serving mothers and infants. The large majority of participants should be responsible for hospitals that are not yet involved in the BFHI or are unsure of the importance of supporting breastfeeding. A few can be in the “committed” category or already “Baby-friendly” to provide good models for others to follow.
- hospital administrator or director;
- head of key department of a large hospital;
- hospital manager;
- provincial or district medical officer (responsible for managing one or more health facilities);
- policy-maker with responsibility for health facility policies or administration at the national or regional level.
The committee should decide whether to involve participants from one type of facility, such as regional hospitals or large teaching hospitals, or whether to have a mix of representatives from public and private hospitals, large and small institutions, maternities and other maternal/child health facilities. Including representatives from different types of health facilities may contribute to livelier discussions. Budget constraints and judgments of which participants are most likely to effect change should help guide selection.
Course organizers may wish to invite several representatives from the same health facility so they can work on plans together. Experience has shown that change happens more quickly when a team of people are working towards the same goals. On the other hand, more institutions can be reached if only one representative attends from each facility.
Another decision concerns whether participants will all be from one region of the country or from the country as a whole. One advantage of inviting participants from one region is that the interaction during the course can encourage networking among the participants and their institutions in support of breastfeeding. Again, budget considerations will probably influence these decisions, as well as how many courses of this type are planned.
Groups of 15–20 people are ideal for promoting discussion during the sessions, although some countries may find it more cost-efficient to invite more participants.
Pre-course communication with participants
A high-level person within the health system, such as the minister of health, should issue letters of invitation in order to ensure attendance of key administrators and policy-makers who have influence and authority.
A questionnaire may be sent with the letter of invitation requesting the participant’s name, mailing address, phone, place of work, title/job position, responsibilities, whether working in or associated with a BFHI hospital, most important challenges/problems faced in making their health facility “Baby-friendly” or supporting breastfeeding, and what is expected from the course (see Annex B for a sample questionnaire).
Participants should be requested to bring to the course data related to infant feeding in their local area or region. This could include rates of exclusive breastfeeding, rates of any breastfeeding, average age infants begin receiving other liquids and food (and types of food), rates of diarrhoeal disease, and KAP studies of mothers, families, and health professionals related to breastfeeding practices. This information will be helpful during discussions on the national situation (Session 1), and for use during the sessions on hospital self-appraisal (Session 7) and development of action plans (Session 8).
Consider the possibility of distributing reading material prior to the course, such as:
- WHO/UNICEF. Protecting, Promoting and Supporting Breast-feeding: The Special Role of Maternity Services. A Joint WHO/UNICEF Statement. Geneva, World Health Organization, 1989.
- International Code of Marketing of Breast-milk Substitutes. Geneva, World Health Organization, 1981.
- WHO/UNICEF. Baby-friendly Hospital Initiative, Section 1 – 1.2 Hospital Level Implementation and 1.3 The Global Criteria for BFHI, In: Baby-friendly Hospital Initiative: revised, updated and expanded for integrated care. Geneva, World Health Organization, 2009.
Emphasize in the cover letter that participants should bring the reading material with them to the course, as it will be referred to during discussions.
Site selection is important to the success of the course. The course facility needs to be attractive to senior level participants with a decision-making capacity, and yet within the budget. If possible, it should be outside the main city, so that participants can concentrate on the course without being distracted by other responsibilities. Travel time and cost of transportation are other important considerations.
The availability of support services and communication systems, such as copy machine, computer and printer, telephones, and fax greatly facilitate organizing and conducting of the course. Nevertheless, if some elements are missing, organizers should do their best to adapt to local conditions.
Appropriate audio-visual equipment and room conditions should be available for presentations (source of electricity, projectors, screens, room-darkening shades or curtains).
A number of smaller breakout rooms or areas for small group work are necessary for sessions 5 and 8. They should be easily accessible to the larger room so facilitators and participants do not waste time going from one site to the other.
If possible, a copy of this full course guide should be provided for each facilitator who has overall responsibility for the course. All presenters need a copy of the relevant course sessions, as well as the PowerPoint file or transparencies to be used for their presentation.
The Session Plans and handouts for each of them are presented in this document, following the Course Guide. PowerPoint files with slides and transparencies for each of the sessions except Session 7 (which has none) can be accessed through links on the course website.
Handouts need to be duplicated for each participant. The handouts can be put in binders for each participant along with the course schedule, lists of participants and presenters, and other relevant documents. At the start of each session, presenters should refer to the documents in the participant binder that pertain to that particular session. Alternatively, handouts can be distributed at the beginning of each session, although this has been found to consume valuable time (worksheets or group work instructions should be passed out when they are needed). A condensed version of the slides is included as a handout and should be copied for participants. This handout allows participants to concentrate on the session while also taking notes.
The PowerPoint slides can be used in settings where a laptop computer and the appropriate projector are available. The sets include slides with text, bar graphs and other data presentations and, when appropriate, photos. All the slides are in colour. Some of the slide sets include photos, which are all listed in Annex C. Slides presenting local data or local photos may, of course, be substituted or added. Presenters should sort through the presentations provided and feel free to adjust them by adding or deleting slides and substituting their own data or photos as desired.
The presenter may decide to use overhead transparencies when a laptop computer and the required projector to show the PowerPoint slides are not available or for sessions for which there are many locally made overheads and it is difficult to switch back and forth between the two media. The PowerPoint transparency files present the “slides” in black and white format suitable for printing and making into transparencies. These files do not include the coloured photo slides, as they do not reproduce well in black and white. Transparencies and slides have identical numbers so that either medium can be used.
The following booklets are considered core resources for the course. There is usually a charge for these documents. If budget permits, it would be best to have a copy for each participant.
- World Health Organization and UNICEF. Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services. A Joint WHO/UNICEF Statement. Geneva, World Health Organization, 1989.
- International Code of Marketing of Breast-milk Substitutes. Geneva, World Health Organization, 1981. http://www
.who.int/nutrition /publications /infantfeeding/code_english.pdfBoth are available from:
A poster of the “Ten Steps” that can be displayed in the classroom is helpful. Contact the UNICEF or BFHI office for a copy.
A slide set or video on “Baby-friendly” for the country or region where the course is being given is recommended for Session 3, if available.
The video/DVD “Delivery Self Attachment” (Dr. L. Righard’s study, 6 minutes, 1992) is recommended for Session 4. It is available from:
- Geddes ProductionsPO BOX 41761Los Angeles CA 90041-0761USAVoice: +1 323 344-8045Fax: +1 323 257-7209
The following are other optional videos currently available. Locally produced videos can also be used to reflect the national experience.
“Breast is Best: About Mother’s Milk, Breast-feeding and Early Contact with the Newborn” by Gro Nylander (1994), 35 minutes. Available in a number of languages from:
- Video Vital A/SSkovveien 33Pb. 5058, Majorstua0301 Oslo, NorwayTel.: +47 22-55-45-88Fax: +47 22-56-19-91
“Hand Expressing and Cup Feeding” by Nursing Mothers’ Association of Australia (1994), 30 minutes. Available from:
- ABA Waverley Group,PO Box 3006, SyndalVIC 3149, Australia.Tel.: +613 9803 9239 - Jenny
Publications that provide additional background information can be purchased if funds are available. Presenters/facilitators may wish to use them in session preparation. They could also be made available to participants as a core library. The following are suggested as general resources:
Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession, Sixth Edition. St. Louis, MO: Elsevier/C.V. Mosby, Inc.; 2005.
Savage-King F. Helping Mothers to Breastfeed, Revised Edition. Nairobi, Kenya: African Medical and Research Foundation; 1992. 1992 (this document is available in a number of languages)
The educational supplies and equipment that will likely be needed for the course are noted in the following checklist.
Prepare for participants ahead of time:
- binders, folders or special bags with schedule and handouts inserted;
- notebooks or paper;
- name tags and place cards (stand up cardboard);
- registration forms;
- necessary paperwork for “out of pocket” money, if applicable;
- evaluation forms;
- lists of names and contact information for presenters, facilitators, and participants.
Have available during the course:
- copier, paper;
- computer and printer, paper;
- overhead projector, extra bulbs;
- laptop computer and LCD (data video) projector for showing PowerPoint presentations, extra bulbs;
- projection stand or table;
- video player, monitor, videos in correct format;
- extension cord(s);
- projection screen;
- flip charts, flip chart stands, markers (ideally one for each small group);
- chalk and erasers if using a blackboard;
- overhead transparencies and markers (if used for reporting group work);
- stapler, staples, paper clips, tape;
- scissors, hole puncher;
- pencils, pencil sharpener, pens;
- books and other documents.
Initial course activities
Registration: Distribution of name tags, folders containing course schedule, documents and handouts.
Questionnaire distribution: The questionnaire described under “Pre-course communication with participants” can be distributed and collected at the beginning of the course if it was not sent out earlier. It is best, however, to ask that it be returned earlier, as participants often arrive just before the course starts and have little time to complete forms.
Introductions: Introduction of speakers/facilitators and participants (they should be name).
Opening ceremonies: Keep as simple and short as possible (optional).
Evaluation and reporting
Responsibility for distribution and collection of evaluation forms and compilation of data needs to be assigned. Sample evaluation forms that can be used during the course are provided in Annex B. They include:
Session evaluation forms to be completed by participants and speakers. These forms may be particularly useful the first few times the course is given.
An overall course evaluation form for the end of the course. An alternative to using the final evaluation form is to schedule a brief discussion period for feedback following the last course session.
A debriefing/evaluation meeting for course organizers and facilitators can be held after the course is over. If additional courses of this type will be held in the future, organizers can learn from this experience in planning for the next one.
Course sponsors and the organizing committee should decide prior to the course what type of report is needed (its purpose and content), and should assign responsibility for report preparation and distribution. This way, those who are responsible can take notes as needed.
Successful implementation of action plans is usually greater if participants know they will need to submit progress reports at a later date and whether technical and financial support is possible. As budget permits, follow-up activities may be carried out following the course by either the national breastfeeding or infant and young child feeding coordinator or the BFHI coordinator. At an appropriate period after completing the course, participants can be sent letters/forms requesting progress reports and statistical data. Lessons learned can be applied to future courses for administrators and policy makers.
It will be necessary at the end of the course to announce exactly what type of monitoring/follow-up will be conducted and when, and what support will be available.
This course can play an important role in continuing the effort to assist maternity facilities to implement the “Ten steps to successful breastfeeding”. Dialogue and problem-solving among colleagues provides the motivation for initiating change. Lasting policy change leading to practices that support breastfeeding is an outcome well worth the effort.
Annex A. Sample agendas for the Decision-makers Course
Sample agenda 1: Two-day version
(note: this two-day version of the agenda is the preferred version, if it is possible for all participants (top-level decision-makers, policy-makers and hospital managers) to attend a full two-day event. It allows for adequate time to explore the key topics related to implementing or revitalizing BFHI that are important for decision-makers, and provides enough time for useful exercises (such as those related to “becoming Baby-friendly”) and for developing full action plans).
Sample agenda 2: One-and-a-half-day version
(note: this day-and-a-half version of the course has been adapted so that the first day would be for all the top-level decision-makers and hospital managers. The morning of the second day could be provided to all participants or, if the top-level decision-makers are “to busy” to stay, it could be attended just by the hospital managers tasked in developing BFHI action plans).
Sample agenda 3: One-day version
(note: this one-day version of the course has been adapted to include only a ½ day orientation for busy top-level decision-makers, along with hospital managers, and an additional afternoon session for hospital managers tasked in developing BFHI action plans. If this shortest version of the course is selected, it will be necessary for course planners to streamline each of the Sessions, choosing the content and PowerPoint slides of most relevance for their audience. If desired, this one-day version of the course can also be used with all participants staying for the entire day).
Annex B. Strengthening and sustaining the Baby-friendly Hospital Initiative: A course for decision-makers
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Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care. Geneva: World Health Organization; 2009. Course guide.