New UN guidance aims to boost exclusive breastfeeding worldwide

UNITED NATIONS — New United Nations guidance aims to standardize breastfeeding and push governments to take ownership of the education and monitoring that could help boost lackluster global rates of exclusively breastfeeding infants.

Questions from health facilities and governments generally revolve around how — as opposed to why — infants under the age of 6 months should be exclusively breastfeed, according to experts from the United Nations Children’s Fund and the World Health Organization. These two organizations jointly issued the revised 10-step guidance in mid-April.

“Most countries know that breastfeeding is best for children, [but] may see challenges when a baby is preterm, or if there are technical difficulties to implement it. The question is more how to do it, and not why do it,” said Maaike Arts, an early childhood nutrition specialist at UNICEF.

While universal breastfeeding could help avoid the deaths of 823,000 children and 20,000 new mothers each year, just 40 percent of babies under the age of 6 months last year were exclusively breastfed within the first 24 hours, according to UNICEF. Breastfeeding rates — relatively stagnant over the last two decades — do not vary widely from region to region, but tend to be higher in low- and middle-income countries.

“We know it [breastfeeding] works,” Arts said. “Our concern was to make it sustainable to be scaled up nationwide, so we focused on different steps that we think make it more sustainable and better to replicate.”

Increasing exclusive breastfeeding to 50 percent by 2025 would require an additional investment of $5.7 billion over 10 years, mostly going toward infant and young child nutrition counseling work, the World Bank has found. But the cost of making the investment could yield $298 billion across low- and middle-income countries, given the avoided loss of cognitive development and child mortality.

The revised U.N. guidance calls for better medical staff training and early information sharing with pregnant women. It marks the third guidance update since 1991, when UNICEF and WHO first launched a Baby-friendly Hospital Initiative, designed to incentivize facilities to become certified.

Globally, about 10 percent of babies are born in facilities that were designated as baby-friendly by UNICEF and WHO, according to UNICEF findings last year.

“It’s pretty telling that 90 percent of facilities are being missed by the current initiative,” said Dr. Laurence Grummer-Strawn, a technical expert at WHO who specializes in infant and early childhood nutrition.

The guidance encourages health facilities to support breastfeeding from birth. They should have a written infant feeding policy that is known by staff and parents, and should ensure that staff have “sufficient knowledge, competence, and skills” to encourage breastfeeding. Doctors, nurses, and midwives should also help new mothers by facilitating immediate skin-to-skin contact and breastfeeding soon after birth.

“With staff training and competency, there is a real shift in the way the new guidance looks at staff having the knowledge and the skills to implement the practices,” said Trish MacEnroe, the executive director of Baby-Friendly USA, one of the nonprofit organizations that collaborated with UNICEF and WHO on the new guidelines. “In the current version, there is a mandatory 20-hour course with a five-hour certification course. The shift now is completely for competency verification. We now have to decide on methodology, who is qualified to do that and how to do it.”

Recommended policy changes could mean exclusive breastfeeding practices are implemented in medical and nursing school curriculum, instead of training doctors and nurses on the guidance after they are already working. New mothers could also be introduced to information on exclusive breastfeeding before, and not just after, they give birth.

“In many cases we are not giving good, solid information to mothers to specifically address their concerns. The answer is a lot of one-on-one conversations,” MacEnroe said. “It begins with us working with mothers — making sure they have evidenced-based information that can help them make an informed decision. The staff also need to have this.”

But pushing breastfeeding on women should not be the intention —  it should be to inform them and make them aware of the health benefits of breastfeeding. Various factors, including lack of maternity leave, could lead mothers to not breastfeed exclusively, and the choice to not breastfeed should be accepted, MacEnroe added.

For now, MacEnroe is encouraging facilities in the U.S. to “stay the course,” until questions on implementation are answered.

A subset target on establishing ongoing monitoring and data management systems is also an addition to the new guidance.

“What we've found from the literature was that many facilities would obtain the designation and demonstrate that they were doing the right things. But then when you come back to see them a few years later, they've drifted away to old practices,” explained Laurence Gummer-Strong, a technical officer at WHO. “You have to have internal monitoring systems checking overtime that you're actually maintaining the right practices and still getting the right outcomes, so that when you start drifting away you can do a course correction.”

Staff turnover can sometimes lead to designated health facilities straying away from guidelines. New staff hired after a facility gets its baby-friendly designation may not be trained appropriately on breastfeeding guidance.

Another issue is the self-regulating nature of the designation, which has relied on health facilities stepping forward and self-identify, rather than this model of care being incorporated into national government health systems.

“What we're really emphasizing with the new guidance is that we can't operate a global program on the basis of volunteers. This really needs to become a standard of care for all babies. It's a human rights approach to say that all babies need good care on infant feeding from birth,” said Grummer-Strawn.

Vietnam is an example of one of the few countries that developed a breastfeeding education and support program, drawing from the 10-step guidance to increase health facility accreditation. In 2009, 20 percent of all babies under the age of 6 months were breastfed exclusively in the country. Rates increased to 62 percent by 2016 in areas with intensive program activity.

Serbia is another country developing a similar program. And in Ghana, work on a quality care breastfeeding initiative is scaling up to the national level. Ghana had an exclusive breastfeeding rate of 46 percent in 2011. Now, it stands at 52 percent, above the regional 41 percent.

Exclusive breastfeeding has benefits for an infant’s cognitive development and for the prevention of noncommunicable diseases. Increased breastfeeding has been found to prevent nearly half of all diarrhea episodes and one-third of respiratory infections, decreasing hospital admissions. Benefits for mothers include decreasing the risk of both breast cancer and postnatal depression.

“I have been working in this area for a long time and what strikes me is the evidence that is coming out is only confirming more and more how important breastfeeding is for child survival,” Art explained. “The idea, though, is to inform people — not to just push it on them.”