NORMAS TÉCNICAS SOBRE REVELACIONES

The BFI was developed by the WHO and UNICEF to improve maternal-infant health by increasing global rates of breastfeeding initiation, duration and exclusivity. The success of the BFI was well documented in the literature with consistent evidence supporting that Baby-

Friendly facilities improve rates of breastfeeding for the populations they serve (Broadfoot, Britten, Tappin & MacKenzie, 2005; Camurdan et al., 2007; Merewood, Mehta, Chamberlain, Phillip & Bauchner, 2005; Merten, Dratva & Ackermann-Liebrich, 2005; Philipp, Malone, Cimo & Merewood, 2003). Three influential studies examining the impact of the BFI are described below. These include a large randomized control trail from Belarus (Kramer et al., 2001), a nationwide study from the United States (Merewood et al., 2005), and a nationwide study from Switzerland (Merten et al., 2005).

The Promotion of Breastfeeding Intervention Trial (PROBIT) was the largest randomized control trial ever conducted in the field of human lactation, with the participation of 17,046 mother-infant pairs in the Republic of Belarus (Kramer et al., 2001). It was designed to assess the impact of the BFI on breastfeeding duration and exclusivity by comparing data on the infant feeding practices and health indicators of babies born in accredited BFI hospitals with those of infants born in non-BFI hospitals. Belarus was selected as the intervention site for this research because it had similar health services, sanitary conditions, and water quality as other developed countries. Mother-infant pairs were drawn from 31 hospitals, of which 16 were randomly selected to model the Baby-Friendly Hospital intervention, and 15 were randomly assigned to continue with usual infant feeding hospital practices. Each hospital selected to model the BFI received training for all staff providing care to mothers and infants and all resources necessary to model the BFI. These were extensively monitored throughout the duration of the study to ensure ongoing compliance with each of the WHO/UNICEF BFI Ten Steps to Successful Breastfeeding.

To participate, mothers had to intend to breastfeed, deliver a healthy full-term infant (singleton birth) weighing more than 2500g between June 1996 and December 1997, and be free of any health conditions or complications. Data were collected from each mother-infant pair at

1, 2, 3, 6, 9, and 12 months, on mode of feeding, infant feeding practices, infant length, weight, head circumference, number of infant clinical visits and hospitalizations, and the occurrence of any respiratory infections, gastrointestinal infections, and rashes. The study compared outcomes from two groups of breastfed infants – those born in a BFI facility, and those born in a non-BFI facility. For this reason, PROBIT does not provide data demonstrating the full benefits of breastfeeding by comparing breastfed versus not breastfed infants, but rather demonstrates the impact of the BFI on breastfeeding duration, exclusivity, and infant health outcomes, when compared with outcomes from non-BFI facilities (Kramer et al., 2001; Martens, 2012).

Results indicated that infants who received the BFI intervention were breastfed exclusively for a longer duration, were breastfed as a mode of complementary feeding for a longer duration, and experienced fewer hospitalizations, gastrointestinal infections, and cases of atopic eczema than infants who were not born in a BFI facility (Kramer et al., 2001; Martens, 2012). Indeed, “the proportion of women exclusively breastfeeding at 3 months was 7-fold higher in the experimental group (43.3% vs. 6.4%); and more than 12-fold higher at 6 months (7.9% vs. 0.6%)” (Kramer et al., 2001, p. 417). In addition to improving rates of exclusive feeding, the BFI intervention was found to decrease the risk of gastrointestinal tract infection in the first year by 40% and reduce the occurrence of atopic eczema by 46% for infants born in BFI facilities versus non-BFI facilities. Study results indicate that the BFI is an effective strategy for increasing breastfeeding rates and improving infant health outcomes in the first year of life. Results also provide valuable baseline data for follow-up on long-term health benefits of BFI practices.

Kramer and authors (2007a) conducted follow-up research on the PROBIT study in Belarus 6.5 years following the intervention to assess the impact of BFI practices on asthma and

allergy, child behaviour, height, weight, blood pressure, childhood obesity, and cognitive

development. Results indicated that although children born in a BFI facility were breastfed for a longer duration, they did not have a reduced risk of asthma or allergy and did not demonstrate behavioural differences when compared to children delivered in non-BFI facilities (Kramer et al., 2007a, 2008a). Additionally, no significant differences were found among groups when

assessing child height, weight, or blood pressure (Kramer et al., 2007a, 2009). Significant differences were found however when comparing child cognitive development among BFI and non-BFI intervention groups. Children from the BFI group were found to have higher IQ scores, higher Wechsler Abbreviated Scale of Intelligence (WASI) scores, and higher overall teacher assessments (focused on reading, writing, and mathematics skills) than those in the non-BFI group (Kramer et al., 2008b).

The effectiveness of the BFI was also explored in a nationwide study in the United States. Merewood and colleagues (2005) reviewed hospital records for 34,365 mother-infant pairs (from 28 BFI institutions) to compare rates of breastfeeding initiation and exclusivity with national rates. Results indicated a significant difference in rates of breastfeeding initiation (83.3%) and exclusivity (78.4%) for mother-infant pairs cared for in BFI facilities compared to the national average of 69.5% and 46.3%, respectively. In addition, higher rates of breastfeeding in BFI facilities were found to continue regardless of the presence of demographic factors commonly associated with low breastfeeding rates, such as low family income or educational attainment. The higher rates of initiation and exclusivity found among mother-infant dyads in BFI facilities indicate that the BFI is a successful initiative for improving breastfeeding rates.

Similar results were reported in a study involving 2,861 mother-infant pairs from 145 health facilities across Switzerland (Merten et al., 2005). Rates of breastfeeding initiation,

duration, and exclusivity were found to be significantly higher among mother-infant pairs who received care in a BFI facility compared with those who did not. Although all hospitals were not designated BFI facilities, hospitals with the greatest adherence to WHO/UNICEF guidelines had the highest rates of breastfeeding duration. Together these studies provide compelling evidence in support of the BFI as an effective initiative for improving rates of breastfeeding initiation, duration, and exclusivity.