Preface for the 2009 BFHI materials: Revised, Updated and Expanded for Integrated Care

Publication Details

Since the Baby-friendly Hospital Initiative (BFHI) was launched by UNICEF and WHO in 1991–1992, the Initiative has grown, with more than 20,000 hospitals having been designated in 156 countries around the world over the last 15 years. During this time, a number of regional meetings offered guidance and provided opportunities for networking and feedback from dedicated country professionals involved in implementing BFHI. Two of the most recent were held in Spain, for the European region, and Botswana, for the Eastern and Southern African region. Both meetings offered recommendations for updating the Global Criteria, related assessment tools, as well as the “18-hour course”, in light of experience with BFHI since the Initiative began, the guidance provided by the new Global Strategy for Infant and Young Child Feeding, and the challenges posed by the HIV pandemic. The importance of addressing “mother-friendly care” within the Initiative was raised by a number of groups as well.

As a result of the interest and strong request for updating the BFHI package, UNICEF, in close coordination with WHO, undertook the revision of the materials in 2004–2005, with various people assisting in the process (Genevieve Becker, Ann Brownlee, Miriam Labbok, David Clark, and Randa Saadeh). The process included an extensive “user survey” with colleagues from many countries responding. Once the revised course and tools were drafted they were reviewed by experts worldwide and then field-tested in industrialized and developing country settings. The full first draft of the materials was posted on the UNICEF and WHO websites as the “Preliminary Version for Country Implementation” in 2006. After more than a year’s trial, presentations in a series of regional multi-country workshops, and feedback from dedicated users, UNICEF and WHO1 met with the co-authors above2 and resolved the final technical issues that had been raised. The final version was completed in late 2007. It is expected to update these materials no later than 2018.

The revised BFHI package includes:

Section 1.

Background and Implementation, which provides guidance on the revised processes and expansion options at the country, health facility, and community level, recognizing that the Initiative has expanded and must be mainstreamed to some extent for sustainability, and includes:


Country Level Implementation


Hospital Level Implementation


The Global Criteria for BFHI


Compliance with the International Code of Marketing of Breast-milk Substitutes


Baby-friendly Expansion and Integration Options


Resources, references and websites

Section 2.

Strengthening and sustaining the Baby-friendly Hospital Initiative: A course for decision-makers was adapted from the WHO course “Promoting breast-feeding in health facilities: A short course for administrators and policy-makers”. This can be used to orient hospital decisions-makers (directors, administrators, key managers, etc.) and policy-makers to the Initiative and the positive impacts it can have and to gain their commitment to promoting and sustaining “Baby-friendly”. There is a Course Guide and eight Session Plans with handouts and PowerPoint slides. Two alternative session plans and materials for use in settings with high HIV prevalence have been included.

Section 3.

Breastfeeding Promotion and Support in a Baby-friendly Hospital, a 20-hour course for maternity staff, which can be used by facilities to strengthen the knowledge and skills of their staff towards successful implementation of the Ten Steps to Successful Breastfeeding. This section includes:


Guidelines for Course Facilitators including a Course Planning Checklist


Outlines of Course Sessions


PowerPoint slides for the Course

Section 4.

Hospital Self-Appraisal and Monitoring, which provides tools that can be used by managers and staff initially, to help determine whether their facilities are ready to apply for external assessment, and, once their facilities are designated Baby-friendly, to monitor continued adherence to the Ten Steps. This section includes:


Hospital Self-Appraisal Tool


Guidelines and Tools for Monitoring

Section 5.

External Assessment and Reassessment, which provides guidelines and tools for external assessors to use both initially, to assess whether hospitals meet the Global Criteria and thus fully comply with the Ten Steps, and then to reassess, on a regular basis, whether they continue to maintain the required standards. This section includes:


Guide for Assessors, including PowerPoint slides for assessor training


Hospital External Assessment Tool


Guidelines and Tool for External Reassessment


The BFHI Assessment Computer Tool

Sections 1 through 4 are available on the UNICEF website at or by searching the UNICEF website at and, on the WHO website at or by searching the WHO website at

Section 5: External Assessment and Reassessment, is not available for general distribution. It is only provided to the national authorities for BFHI who provide it to the assessors who are conducting the BFHI assessments and reassessments. A computer tool for tallying, scoring and presenting the results is also available for national authorities and assessors. Section 5 can be obtained, on request, from the country or regional offices or headquarters of UNICEF Nutrition Section and WHO, Department of Nutrition for Health and Development.



Moazzem Hossain, UNICEF NY, played a key role in organizing the multi-country workshops, launching the use of the revised materials. He, Randa Saadeh and Carmen Casanovas of WHO worked together with the co-authors to resolve the final technical issues.


Miriam Labbok is currently Professor and Director, Center for Infant and Young Child Feeding and Care, Department. of Maternal and Child, University of North Carolina School of Public Health.