Evidence on the importance of breastfeeding as the cornerstone of child survival, nutrition and development and maternal health continues to increase. A series of systematic reviews have shown the effect of breastfeeding in decreasing child infections and dental malocclusion and increasing intelligence. Mothers who breastfeed are at decreased risk of breast cancer. Improving breastfeeding rates globally can prevent over 800 000 deaths in children under 5 years of age and 20 000 deaths from breast cancer annually. Not breastfeeding is associated with annual economic losses of over US$ 300 billion worldwide or 0.5% of the world’s gross income (1–13).
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 (14–16). In 2012, the World Health Assembly Resolution 65.6 endorsed a Comprehensive implementation plan on maternal, infant and young child nutrition (15), 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% (17). Currently, only 37% of infants younger than 6 months of age are exclusively breastfed (2).
Women need support in order to optimize their chances of breastfeeding in line with WHO’s recommendations. There is evidence showing that implementation of the Ten Steps to Successful Breastfeeding, as listed in the WHO and United Nations Children’s Fund (UNICEF) joint statement Protecting, promoting and supporting breastfeeding: the special role of maternity facilities (18), emphasized in the Innocenti Declarations on infant feeding (19, 20) and incorporated in the Baby-friendly Hospital Initiative (21, 22) (see Box 1), have a positive impact on breastfeeding outcomes (12, 23–25), with a dose–response relationship between the number of interventions the mothers are exposed to and improved outcomes (23).
Ten Steps to Successful Breastfeeding (18–).
This guideline examines each of the practices of the Ten Steps to Successful Breastfeeding, in order to bring together evidence and considerations to inform practice. It provides global, evidence-informed recommendations to support Member States in enabling protection, promotion and support of breastfeeding in facilities providing maternity and newborn services, as a public health intervention, in order to improve breastfeeding, health and nutrition outcomes.
Objectives
This guideline provides global, evidence-informed recommendations on protection, promotion and support of optimal breastfeeding in facilities providing maternity and newborn services, as a public health intervention, to protect, promote and support optimal breastfeeding practices and improve nutrition, health and development outcomes.
This guideline is intended to contribute to discussions among stakeholders when selecting or prioritizing interventions to be undertaken in their specific context. The guideline presents the key recommendations, a summary of the supporting evidence and a description of the considerations that contributed to the deliberations and consensus decision-making. It is not intended as a comprehensive operational manual or implementation tool for the Baby-friendly Hospital Initiative (21, 22), the International Code of Marketing of Breast-milk Substitutes (26) or other breastfeeding protection, promotion and support programmes.
This guideline aims to help WHO Member States and their partners to make evidence-informed decisions on the appropriate actions in their efforts to achieve the Sustainable Development Goals (27) and the global targets for 2025 as put forward in the Comprehensive implementation plan on maternal, infant and young child nutrition (15), endorsed by the Sixty-fifth World Health Assembly in 2012, in resolution WHA65.6, the Global strategy for women’s, children’s, and adolescents’ health (2016–2030) (16), and the Global strategy for infant and young child feeding (14).
Scope
This guideline, Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services is an update of, and supersedes, the Ten Steps to Successful Breastfeeding, as listed in the joint statement of WHO and UNICEF in 1989, Protecting, promoting and supporting breastfeeding: the special role of maternity services (18). This complements the operational guidance of the Innocenti Declaration on the protection, promotion and support of breastfeeding (19), adopted in Florence, Italy in 1990, and the Innocenti Declaration on infant and young child feeding (20) published in 2005. It also complements some of the operational guidance in the Baby-friendly Hospital Initiative published in 1991 (21) and updated in 2009 (22) (only inasmuch as aspects of the Ten Steps to Successful Breastfeeding remain unchanged).
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 Breast-milk Substitutes (26), 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 (28). 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 (23).
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 facilities 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 (26, 28).
This guideline complements interventions presented in the Essential newborn care course (29), Kangaroo mother care: a practical guide (30), Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice (31) and the Standards for improving quality of maternal and newborn care in health facilities (32) 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 (26) and the Baby-friendly Hospital Initiative (22) 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.
Target audience
The recommendations in this guideline are intended for a wide audience, including policy-makers, their expert advisers, and technical and programme staff at government institutions and organizations involved in the design, implementation and scaling-up of programmes for infant and young child feeding. The guideline may also be used by health-care professionals, clinicians, universities and training institutions, to disseminate information.
The end-users of this guideline are:
national and local policy-makers;
implementers and managers of national and local nutrition programmes;
nongovernmental and other organizations and professional societies involved in the planning and management of nutrition actions;
administrative and health workers involved in policy-making, information sharing, education and training in hospitals, facilities providing maternity and newborn services and other institutions that provide maternity services;
health professionals, including managers of nutrition and health programmes and public health policy-makers in all settings;
health workers in facilities providing maternity and newborn services.
Population of interest
This guideline will affect women delivering in hospitals,1 maternity facilities2 or other facilities providing maternity and newborn services, and their infants.
These include mother–infant pairs with term infants, as well as those with preterm, low-birth-weight or sick infants and those admitted to neonatal intensive care units. There is further guidance for low-birth-weight infants from the WHO Guidelines on optimal feeding of low birth-weight infants in low- and middle-income countries (33). Infants who are, or who have mothers who are, living with HIV can, in addition, be referred to current guidelines on HIV and infant feeding (34–36).
Infants born at home or in the community setting and those with medical reasons not to breastfeed, temporarily or permanently (37), will not be considered in this guideline.
Priority questions
The following key questions were posed, based on the policy and programme guidance needs of Member States and their partners. The population, intervention, comparator, outcomes (PICO) format was used. The key questions listed next give an example of one of the critical outcomes considered. The questions, with population and intervention subgroups and a full list of critical outcomes, guiding the evidence review and synthesis for the recommendations in this guideline are listed in Annex 1.
Immediate support to initiate and establish breastfeeding
Should mothers giving birth (P) practise early skin-to- skin contact (I), compared to not practising early skin-to-skin contact (C), in order to increase rates of early initiation of breastfeeding within 1 hour after birth (O)?
Should mothers giving birth (P) practise early initiation of breastfeeding (I), compared to not practising early initiation of breastfeeding (C), in order to increase rates of exclusive breastfeeding during the stay at the facility (O)?
Should mothers giving birth (P) be assisted with correct positioning and attachment, so that their infants achieve proper effective suckling (I), compared to not assisting mothers to position and attach (C), in order to increase rates of exclusive breastfeeding during the stay at the facility (O)?
Should mothers giving birth (P) be shown how to practise expression of breast milk (I), compared to not being shown expression of breast milk (C), in order to increase rates of exclusive breastfeeding during the stay at the facility (O)?
Should mothers giving birth in hospitals or facilities providing maternity and newborn services and their infants (P) remain together or practise rooming-in (I), compared to not rooming-in (C), in order to increase rates of exclusive breastfeeding during the stay at the facility (O)?
Should mothers giving birth (P) practise feeding on demand or responsive feeding or infant-led breastfeeding (I), compared to not practising feeding on demand or feeding by schedule (C), in order to increase rates of exclusive breastfeeding during the stay at the facility (O)?
Feeding practices and additional needs of infants
Should newborn infants (P) be given no foods or fluids other than breast milk unless medically indicated (I), compared to giving early additional food or fluids (C), in order to increase rates of exclusive breastfeeding during the stay at the facility (O)?
Should infants (P) not be allowed to use pacifiers or dummies (I), compared to allowing use of pacifiers or dummies (C), in order to increase rates of exclusive breastfeeding during the stay at the facility (O)?
Should infants who are or will be breastfed (P) not be fed supplements with feeding bottles and teats but only by cup, dropper, gavage, finger, spoon or other methods not involving artificial teats (I), compared to using feeding bottles and teats (C), in order to increase rates of exclusive breastfeeding during the stay at the facility (O)?
Creating an enabling environment
Should hospitals and facilities providing maternity and newborn services (P) have a written breastfeeding policy that is routinely communicated to staff (I), compared to those without a written breastfeeding policy (C), in order to increase rates of early initiation of breastfeeding (O)?
Should health-facility staff (P) be trained on breastfeeding and supportive feeding practices (I), compared to not being trained (C), in order to increase rates of early initiation of breastfeeding (O)?
Should mothers giving birth (P) be given antenatal breastfeeding education (I), compared to not having antenatal breastfeeding education (C), in order to increase rates of exclusive breastfeeding during the stay at the facility (O)?
Should mothers giving birth in hospitals or facilities providing maternity and newborn services (P) be given linkage to continuing breastfeeding support after discharge from the facilities (I), compared to not providing any linkage to continuing breastfeeding support after discharge (C), in order to increase rates of exclusive breastfeeding at 1 month (O)?
Outcomes of interest
The outcomes of interest considered critical for decision-making included the following:
Infant outcomes
Early skin-to-skin contact
Early initiation of breastfeeding within 1 hour after birth
Early initiation of breastfeeding within 1 day after birth
Exclusive breastfeeding during the stay at the facility
Exclusive breastfeeding at 1 month
Exclusive breastfeeding at 3 months
Exclusive breastfeeding at 6 months
Duration of exclusive breastfeeding (in months)
Duration of any breastfeeding (in months)
Morbidity (respiratory infections, diarrhoea, others)
Neonatal, infant or child mortality (all-cause)
Maternal outcomes
Onset of lactation
Breast conditions (sore or cracked nipples, engorgement, mastitis, etc.)
Effectiveness of breast-milk expression (volume of breast milk expressed)
Facilities providing maternity and newborn services and staff outcomes
Awareness of staff of the infant feeding policy of the hospital
Knowledge of health-care workers on infant feeding
Quality of skills of health-facility staff in improving practices of mothers in optimal infant feeding
Attitudes of staff on infant feeding
Adherence to the provisions of the
International Code of Marketing of Breast-milk Substitutes (
26)
For each of the PICO questions, potential harms of the interventions were also considered as important outcomes. The key questions and outcomes guiding the evidence review and synthesis for the recommendations in this guideline are listed in Annex 1.
Presentation of the recommendations
The recommendations on protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services were classified into three domains: (i) immediate support to initiate and establish breastfeeding; (ii) feeding practices and additional needs of infants; and (iii) creating an enabling environment.
Prior to presenting each domain and the considerations for each of the PICO questions, the summary of considerations for determining the direction of the recommendations that apply to all PICO questions was presented. These include:
Each domain is presented in a separate section covering the following contents:
summary of evidence from systematic reviews for each of the interventions;
summary of considerations for determining the direction of the recommendations that apply to each individual PICO question, which includes:
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quality of the evidence;
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balance of benefits and harms;
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values and preferences of mothers;
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acceptability to health workers;
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resource implications.
Three options for types of recommendations were agreed by the guideline development group, namely:
At the end of each section, a short summary brings together:
Table of standardized statements about effect (39).
Description of the interventions
The following section describes the operational definitions used to gather and synthesize evidence that informed the recommendations.
Immediate support to initiate and establish breastfeeding
Interventions relating to immediate support to initiate and establish breastfeeding focus on the critical first hours or days after delivery at the facilities providing maternity and newborn services. These include early skin-to-skin contact, early initiation of breastfeeding, rooming-in and demand feeding.
Skin-to-skin contact is when the infant is placed prone on the mother’s abdomen or chest in direct ventral-to-ventral skin-to-skin contact. Immediate skin-to-skin contact is done immediately after delivery, less than 10 minutes after birth. Early skin-to-skin contact was defined as beginning any time from delivery to 23 hours after birth. Skin-to-skin contact should be uninterrupted for at least 60 minutes. The infant is thoroughly dried and kept warm (for instance by being covered across the back with a warmed blanket). Among preterm and low-birth-weight infants, kangaroo mother care (30) involves similarly placing the infant in skin-to-skin contact, and firmly attached to the mother’s chest, often between the breasts, as soon as the infant is able. Kangaroo mother care can be shared with other providers of skin-to-skin contact, often with the mother’s partner, the other parent of the infant, close kin or an accompanying person. Comparators included dressed or swaddled infants held in the arms or placed in cribs or elsewhere.
Early initiation of breastfeeding involves a breastfeeding initiation time of within 1 hour after birth. Delayed breastfeeding initiation means initiating breastfeeding after the first hour after birth (2–23 hours after birth or a day or more after birth). Infants placed skin-to-skin usually find their own way to the breast and attach spontaneously, unless sedated by analgesics given to the mother.
Showing mothers how to breastfeed is a complex mix of supportive interventions (practical, emotional, motivational or informational) that enable mothers to breastfeed successfully. This support usually involves showing mothers how to hold and position their infant to attach to the breast, and presenting opportunities to discuss and assist with questions or problems with breastfeeding.
Showing mothers how to express breast milk can be useful to reassure mothers that milk is being produced by their breasts (particularly in the first few days after birth) and, eventually, to enable a mother to provide breast milk in the event that she will need to be separated from her infant. Expression of breast milk is primarily done or taught through hand expression, with the use of a mechanical pump only when necessary. The systematic review on expression of breast milk (40) included studies that provided instruction or a support protocol for hand expression or mechanical pumping (with provision of mechanical pumping equipment).
Rooming-in involves keeping mothers and infants together in the same room, immediately after leaving the labour or delivery room after a normal facility birth or from the time when the mother is able to respond to the infant, until discharge. This means that the mother and infant are together throughout the day and night, apart from short intervals when the mother has a specific need, for instance, to use the bathroom. The comparison intervention is that mothers and infants are roomed separately for all or part of the time, and the primary site of care for the infant is the facility nursery during the hospital stay.
Demand feeding (or responsive feeding or baby-led feeding) involves recognizing and responding to the infant’s display of hunger and feeding cues and readiness to feed, as part of a nurturing relationship between the mother and infant. Demand, responsive or baby-led feeding puts no restrictions on the frequency or length of the infants’ feeds, or the use of one or both breasts at a feed, and mothers are advised to breastfeed whenever the infant shows signs of hunger, or as often as the infant wants. The comparator, scheduled feeding, involves a predetermined, and usually time-restricted, frequency and schedule of feeds.
Feeding practices and additional needs of infants
Interventions that relate to feeding practices and additional needs of infants include issues around early additional food or fluids, pacifiers or dummies, and feeding bottles and teats.
Early additional foods or fluids are any feeds given before 6 months of life, the recommended duration of exclusive breastfeeding. In the facilities providing maternity and newborn services, this can be in the form of pre-lacteal feeds given before the first breastfeed, of either colostrum, water, glucose water or artificial milk given outside of the WHO guidance on Acceptable medical reasons for use of breast-milk substitutes (37).
Avoidance of pacifiers or dummies involves advising mothers to avoid offering pacifiers or dummies and may, in addition, involve teaching mothers alternative methods to calm and soothe their infants. Unrestricted pacifier use means that pacifiers or dummies can be offered liberally to infants to suck on during their stay at the facility providing maternity and newborn services. Non-nutritive sucking or oral stimulation among preterm infants, which occurs in the absence of nutrient flow to facilitate sucking behaviour, often involves the use of pacifiers, a gloved finger or a breast that is not yet producing milk.
Avoidance of feeding bottles and teats involves offering oral feeds (of expressed breast milk or, when medically indicated, a combination of expressed breast milk and other fluids) without using feeding bottles and teats, but instead feeding by cup, dropper, gavage, finger or spoon when the infant is not on the breast.
Creating an enabling environment
Effective and sustained improvement in practices often requires appropriate policies and a supportive environment. At the facilities providing maternity and newborn services, interventions considered under the domain of creating an environment to enable mothers to breastfeed include having a written breastfeeding policy, training of health workers, antenatal breastfeeding education and preparation for mothers, and discharge planning and linkage to continuing breastfeeding support.
Breastfeeding policies in facilities providing maternity and newborn services need to cover all established standards of practice and be fully implemented and publicly and regularly communicated to staff. They help to focus on social, environmental and practical factors that affect a mother’s ability to breastfeed her infant. The systematic review on breastfeeding policies in facilities (41) included all randomized controlled trials, cluster randomized trials, quasi-randomized trials, non-randomized trials and observational studies evaluating facilities with a written breastfeeding policy.
Training of health workers enables them to build on existing knowledge and develop effective skills, give consistent messages and implement policy standards according to their roles. The systematic review on training of health workers (42) included all randomized controlled trials comparing breastfeeding education and training for health workers with no or usual training and education.
Antenatal breastfeeding education for mothers can encourage discussion, help prepare mothers practically and promote initiation of breastfeeding after delivery. It may include counselling and information given in a variety of ways. Antenatal breastfeeding education differs from breastfeeding support in that breastfeeding support is given postnatally to the individual mother according to her needs at that time: psychological, physical, financial or targeted information. Two systematic reviews were reported, one on antenatal breastfeeding education (43) and a second on broader antenatal breastfeeding-promotion activities to encourage initiation of breastfeeding (44), which included studies with support from nonhealth- care professionals.
Discharge planning and linkage to continuing support: before discharge from the facility providing maternity and newborn services, it is necessary to plan for breastfeeding after discharge and to provide linkage to continuing and consistent support outside the facility, to help mothers to sustain breastfeeding. A systematic review was done to assess the evidence around providing linkage to further breastfeeding support (45). The review did not assess the effects of any actual breastfeeding support after discharge (such as peer support, clinical support or specialized lactation support), but rather the linkage to further support made by the facilities.
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A hospital is defined as any health facility with inpatient beds, supplies and expertise to treat a woman or newborn with complications (31).
- 2
A maternity facility is defined as any health centre with beds or a hospital where women and their newborns receive care during childbirth and delivery, and emergency first aid (31).
