global baby-friendly hospital initiative monitoring data: update and
TRANSCRIPT
Original Articles
Global Baby-Friendly Hospital Initiative Monitoring Data:Update and Discussion
Miriam H. Labbok
Abstract
Background: The World Health Organization (WHO)/UNICEF Baby-Friendly Hospital Initiative (BFHI) wasdeveloped to support the implementation of the Ten Steps for Successful Breastfeeding. The purpose of thisstudy is to assess trends in the numbers facilities ever-designated ‘‘Baby-Friendly,’’ to consider uptake of the newWHO/UNICEF BFHI materials, and to consider implications for future breastfeeding support.Materials and Methods: The national contacts from the 2006–2007 UNICEF BFHI update were recontacted, aswere WHO and UNICEF officers worldwide, to ascertain the number of hospitals ever-designated ‘‘Baby-Friendly,’’ presence of a government breastfeeding oversight committee, use of the new BFHI materials and, ifyes, use of the new maternity or human immunodeficiency virus (HIV) materials.Results: Seventy countries reporting in 2010–2011 and the updates from an additional 61 reporting in 2006–2007(n = 131, or 66% of the 198 countries) confirm that there are at least 21,328 ever-designated facilities. This is 27.5%of maternities worldwide: 8.5% of those in industrialized countries and 31% in less developed settings. In 2010,government committees were reported by 18 countries, and 34 reported using the new BFHI materials: 14reported using the maternity care and 11 reported using the HIV materials.Conclusions: Rates of increase in the number of ever-certified ‘‘Baby-Friendly’’ hospitals vary by region andshow some chronological correlation with trends in breastfeeding rates. Although it is not possible to attributethis increase to the BFHI alone, there is ongoing interest in Ten Steps implementation and in BFHI. The con-tinued growth may reflect the dedication of ministries of health and national BFHI groups, as well as increasingrecognition that the Ten Steps are effective quality improvement practices that increase breastfeeding andsynergize with community interventions and other program efforts. With renewed interest in maternal/neonatalhealth, revitalization of support for Ten Steps and their effective institutionalization in maternity practicesshould be considered. Future updates are planned to assess ongoing progress and impact, and ongoing updatesfrom national committees are welcome.
Background
The Ten Steps for Successful Breastfeeding in MaternityServices were developed in the late 1980s in the docu-
ment Protecting, Promoting and Supporting Breast-feeding: TheSpecial Role of Maternity Services1 in recognition of the impactof breastfeeding in infant and child health and survival.These Ten Steps served as the basis for the development ofthe World Health Organization (WHO)/UNICEF Baby-Friendly Hospital Initiative (BFHI). BFHI was launched in1991 following the Innocenti Declaration call for all hospi-tals to practice the Ten Steps, as ‘‘Operational Target 2:Ensure that every facility providing maternity services
fully practises all 10 of the ‘Ten Steps to Successful Breast-feeding’.’’
The BFHI was designed to encourage and monitor globalprogress on the Ten Steps by offering more than the Ten Stepsalone; BFHI materials include guidance for planning nationalprograms, training of hospital clinical staff and administra-tors, self-appraisal forms, and facility designation in recog-nition of the facility’s implementation of the Ten Steps amongother additional materials. To receive this designation, inter-nal and external review and assessment processes must reflecta defined minimal level of achievement. UNICEF has moni-tored the number of the BFHI-designated hospitals over theyears2 and more recently as part of a broader effort to assess
Carolina Global Breastfeeding Institute and Department of Maternal and Child Health, Gillings School of Global Public Health, Universityof North Carolina, Chapel Hill, North Carolina.
The author alone is responsible for the views expressed in this publication, and these views do not represent the opinion or policiesof UNICEF.
BREASTFEEDING MEDICINEVolume 7, Number 4, 2012ª Mary Ann Liebert, Inc.DOI: 10.1089/bfm.2012.0066
210
the scope and scale of all infant and young child feeding in-terventions in developing countries.3
The positive health and emotional sequelae of breastfeed-ing for the mother as well as the child are better understoodtoday. In addition to child health and survival, these includeimproved recovery following delivery, decreased blood losspostpartum, delayed return to fertility, and decreased risk ofbreast and ovarian cancers. The ‘‘Baby-Friendly’’ approachsupports immediate postpartum breastfeeding, helping thebonding between mother and child as well as conveying allthe known benefits of breastfeeding, including a reduction incases of abandoned babies.4
Therefore, the Ten Steps and BFHI would seem to remain asrelevant in the new millennium as when they were first con-sidered, given the increasing emphases on safe motherhood,maternal/newborn health, and comprehensive approachesincluding the community. In fact, the 2005 Innocenti + 15meeting, co-sponsored by UNICEF, WHO, World Alliance forBreastfeeding Action (WABA), and others, reviewed progresssince 1990 and called for revitalization of the Ten Steps and forexpansion beyond the hospital setting.2 Innocenti + 15 con-cluded, ‘‘Exclusive breastfeeding increased in many regions,even in the face of continued advertising of commercial infantfoods and increasing HIV [human immunodeficiency virus]prevalence, possibly due to the BFHI alone or in combinationwith other efforts.’’2 According to the WABA, ‘‘The BFHI wasclearly the right initiative at the right time. It galvanized nu-merous resources available globally and provided a focus andfacilitated political will at the highest levels as never before.’’5
The challenges identified at Innocenti + 152 included thefollowing:
1. Commitment. Staff turnovers, the departure of BFHIsupporters, or competing issues result in decliningBFHI practices in some of the designated facilities.
2. Insufficient ownership by governments. The initiative wasoften seen as a UNICEF/WHO endeavor, rather than anational priority.
3. Compliance and quality control. Incorporation of BFHIcriteria into general quality control and accreditationsystems may be needed for sustainability.
4. Cost. There are some capital costs to change trainingand systems.
5. Community outreach. Step 10—community outreach—has not been actively implemented or maintained inmany countries.
6. Confusion and concerns regarding HIV. The HIV/acquired immunodeficiency syndrome pandemic hasbeen associated with confusion and concerns aboutbreastfeeding and related ‘‘Baby-Friendly’’ activities.
7. Extending the continuum of care. Additional attention tomaternity care and intrapartum care is needed.
8. Mainstreaming/integration. The principles of ‘‘Mother-‘‘and ‘‘Baby-Friendly’’ may also be integrated with otherinitiatives. To support the sustainability of Baby-Friendly Hospital practices, full integration of thesepractices into all ongoing activities in support of Mil-lennium Development Goals 1 (Eradicate extremepoverty and hunger), 4 (Reduce child mortality), and 5(Improve maternal health) is a way to ensure thematernal–newborn–child health continuum. Hence, allTen Steps of BFHI are part of quality care of the newborn.
Notwithstanding these challenges, BFHI continued to be acentral component of strengthening breastfeeding supportand early initiation, as well as health-worker training. Assuggested by the Innocenti + 15 outcomes, UNICEF andWHO updated and revised the BFHI documents and com-menced country piloting; The Baby-Friendly Hospital In-itiative: Revised, Updated and Expanded for Integrated Care6 waspublished in 2009.7
The impact of the Ten Steps has been shown at the hospitallevel in many studies in recent years,8,9 and national-levelimpact has also been noted.10 One analysis of global impactfound a clear point of increase in exclusive breastfeedingwith the implementation of the Ten Steps through BFHI. Thisanalysis included only those countries for which multipleDemographic and Health Survey/Multiple Indicator ClusterSurvey survey data are available and then adjusted all datato the year that the BFHI was initiated in each country.11
The lines in Figure 1 indicate the rate of increase in ex-clusive breastfeeding (EBF) in infants < 2 months and the
FIG. 1. Impact of the initiation of the Baby-Friendly Hospital Initiative (BFHI) on the rate ofincrease in exclusive breastfeeding (EBF) in coun-tries where both BFHI information and exclu-sive breastfeeding trend data are available. (Withpermission, from International BreastfeedingJournal).11
GLOBAL REPORT ON BFHI 211
rate for 0–6 months. There is an association between the in-creased rate of exclusive breastfeeding following im-plementation of BFHI, as indicated by the first report of ahospital achieving and being designated as fully practicingthe Ten Steps. For the countries in this study, if the rate ofincrease in exclusive breastfeeding had continued to grow atthe pre-BFHI rates, the percentage of exclusive breastfeedingwould have been nearly 15% lower, closer to 25% rather thanthe 42% seen in these countries.11
The purpose of the current study is to update data on thenumber of facilities ever-designated ‘‘Baby-Friendly,’’ assesstrends, explore the implementation of the revised and expandedBFHI worldwide, examine the relationship of this effort withglobal trends in exclusive breastfeeding, consider whether theacceptance of the new materials has influenced forward mo-mentum, and discuss possible synergy with other programming.
Materials and Methods
UNICEF monitored the status of the BFHI, including re-certification, from the early 1990s. At the request of the WABAand with UNICEF agreement and offering of contact infor-mation, the author e-mailed all available national BFHIcontacts from the 2006–2007 UNICEF update, as well ascurrent UNICEF regional officers and many country officers,and many personal contacts. Informants were asked to com-plete a brief survey that included number of hospitals ever-designated, presence of a government breastfeeding oversightcommittee, use of the new BFHI materials, and, if in use,whether the new maternity or HIV materials were in use. It isimportant to note that the status of ‘‘ever-designated’’ is notnecessarily reflective of current practices; many hospitals donot maintain all practices, and some have reverted to earlierpractices over the many years since the original designation.However, during the period of rapid increase, it is reasonableto assume that following the process of designation that thepractices remained in place for a period of years.
All data from this survey were entered onto an Excel (Mi-crosoft) spreadsheet, along with data gathered by UNICEFsince the 1990s, in 1–4-year intervals. The data are reflective ofthe level of dedication to accurate reporting and are expectedto have some unreported activity. Although not all countriesreported on all data requested, for the purposes of global re-porting, the data submitted are assumed to be reasonablyaccurate (see Discussion). Excel software was used to generatedescriptive and trend data and graphs.
Additional data sources for breastfeeding rates and pro-gram activities used in analysis are cited in the text.
Ethical consideration: This study is considered exempt as itincludes only program data with no personal identifiers.UNICEF personnel supported this effort with their time andreview of early and final drafts of this paper; however, theauthor alone is responsible for the views expressed in thispublication, and these views do not necessarily representthe opinion or policies of UNICEF, WHO, or any otherorganization.
Findings
Number of hospitals ever-designated
Updates were received from 70 countries in 2010–2011, andan additional 61 were updated in 2006, for a total of 131, or66% of countries worldwide. In addition to updates, nearly allcountries reported at some point during this period, with theremainder generally reporting no change. Table 1 shows thenumber and percent of respondents by region, developmentstatus, and total.
The number of hospitals ever-designated has increased;according to the most recent data, there are a reported 21,328hospitals worldwide that have ever been designated. Thisrepresents about 27.5% of all maternities worldwide: about8.5% of facilities in industrialized countries and about 31% inless developed settings.
Table 1. Number of Countries Reporting on Hospitals Ever-Designated as ‘‘Baby-Friendly’’
Number of countries responding at least once, by region and time period indicateda
1995–2001 2006–2011
Respondents(n) (estimated)
% responsewithin region
Regionalresponses as % of
all responsesRespondents
(n)% response
within region
Regionalresponses as %of all responses
Total 198 100 100 131 66 100Industrialized countries 37 100 19 31 84 24Developing countries 161 100 81 100 62 76
By region:Americas/Caribbean 39 100 20 18 46 14CEE/CIS 22 100 11 20 91 15EAPRO 26 100 13 23 88 18ESARO 23 100 12 15 65 11MENA 20 100 10 10 50 8South Asia 8 100 4 5 63 4WCARO 23 100 12 9 39 7
aPercents may not add to totals due to rounding.CEE/CIS, Central and Eastern Europe and the Commonwealth of Independent States; EAPRO, East Asia and the Pacific Region; ESARO,
Eastern and Southern Africa; MENA, Middle East/North Africa; WCARO, West and Central Africa.
212 LABBOK
Trends in reporting
The rates of response to the surveys have shifted over theyears (Table 1). The rate of response from industrializedcountries is higher (84% vs. 62% of developing countries).Central and Eastern Europe and the Commonwealth of In-dependent States—the newly independent states—and EastAsia and the Pacific countries continue to have higher ratesof response, whereas West and Central Africa, the SouthAmerican/Caribbean nations, and the Middle East/NorthAfrica region countries have declined to 39%, 46%, and 50%,respectively.
Government authority/committee and uptakeof new materials
Only 18 of the 70 respondents in 2010–2011 reported anactive government committee, and about half of all reporting(n = 34) are beginning to use the new BFHI materials (Table 2).Of these, 14 reported using the new materials for maternitycare, and 11—all in less developed settings—reported usingthe new HIV module (Table 2).
Numbers, rates, and trends in BFHI and facilitiesever-designated
The number of countries that have ever implemented BFHIhas increased over the years. About 160 countries around theworld have initiated BFHI, using the indicator as ever havingdesignated a hospital; however, some of the 38 that have notas yet designated a hospital are, nonetheless, working to-wards this goal.
Table 3 includes the responses of UNICEF officers andcountry programs over the years as collected by UNICEFthrough 2006 and updated at the request of WABA for 2009–2011. The countries that responded in 2006 are bolded andthose responding in 2010 are in italics.
Figure 2 shows the trend in total number of hospitals ever-designated. Please note this is not current status as many mayhave ceased compliance. There is an apparent slowing in theincrease in the numbers ever-designated in about the year
2000. However, the rate appears to increase again withinabout 2–3 years. There is another apparent decline in the rateof increase in the last 3 years.
Figures 3 and 4 illustrate the percentages of hospitals ever-designated ‘‘Baby-friendly’’ for developing countries, in-dustrialized countries, and total. The increase in the rate ofdesignation appears to slow in many regions prior to andcontinuing after 2000, while the rate in industrialized coun-tries picks up substantially a few years later, about 2004.
Relationship with exclusive breastfeeding rates
The rates of exclusive breastfeeding appear to have in-creased worldwide since the Innocenti Declaration of 1990(Figure 5, discussed below). The relationship between anysingle national program and measurable breastfeeding be-havior change is difficult to measure because of the manyother programs and social factors that may also influenceexclusive breastfeeding rates. In order explore this generalrelationship, chronological association may provide someinsights. The trends in percent of facilities ever-designated ineach of the UNICEF regions are illustrated in Figure 4. As maybe seen, not all regions have proceeded in parallel; somestarted up rapidly but then became relatively quiescent,whereas other exhibited later surges. It is notable that BFHI inindustrialized settings and in the Central and Eastern Europeand the Commonwealth of Independent States seems to havetaken off within the last 7 years or so.
Figure 5 presents available data on the percentage of ex-clusive breastfeeding among all infants 0–6 months of age,taken from several UNICEF-published and Childinfo.orgavailable analyses. These analyses were not designed to befully comparable and are presented for the purpose of generalvisualization of the relationship between timing of increasesin BFHI programming and timing of surges in exclusivebreastfeeding rates. For some regions, there appears to bechronological association. Eastern and Southern Africa andWest and Central Africa exhibited a steady and continuingincrease in Baby-Friendly Hospitals until about 2006, and theexclusive breastfeeding rates increased and then leveled, in
Table 2. Numbers and Percentages of Respondents Reporting National Government
Authorities/Committees and Implementation of New Materials in 2009–2011, by Region and Total
Number ofrespondents
Activemultidisciplinary
government committee
Using newBFHI
materialsUse of new
maternal questionsUse of new
HIV modules
n % n % n % n %
Total 70 18 26 34 49 14 20 11 16Industrialized countries 19 4 21 9 47 2 11 0 0Developing countries (total) 51 14 27 25 49 12 24 11 22
Developing countries (by region)Americas/Caribbean 6 1 17 5 83 3 50 2 33CEE/CIS 8 4 50 5 63 0 0 0 0EAPRO 19 5 26 5 26 4 21 3 16ESARO 9 3 33 6 67 2 22 5 56MENA 4 1 25 2 50 2 50 0 0South Asia 4 0 0 2 50 1 25 1 25
BFHI, Baby-Friendly Hospital Initiative; CEE/CIS, Central and Eastern Europe and the Commonwealth of Independent States; EAPRO,East Asia and the Pacific Region; ESARO, Eastern and Southern Africa; HIV, human immunodeficiency virus; MENA, Middle East/NorthAfrica; WCARO, West and Central Africa.
GLOBAL REPORT ON BFHI 213
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06–2
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are
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yit
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s.R
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.In
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asan
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ein
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and
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ics.
CE
E/
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aste
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pe
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EN
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pie
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tory
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CA
RO
,W
est
and
Cen
tral
Afr
ica.
218
parallel. Middle East/North Africa surged early in terms ofincreasing rates of BFHI, slowing rapidly after 1997; exclusivebreastfeeding rates seem to have flattened or slowed.
Comparable breastfeeding data for exclusive breastfeedingrates over this two-decade time period are not available forindustrialized countries, the Americas and Caribbean, orCentral and Eastern Europe and the Commonwealth of In-dependent States.
Discussion
The continued growth in the number of facilities ever-designated as Baby-Friendly is testimony to the recognitionthat implementation of the Ten Steps is an effective qualityimprovement activity to increase breastfeeding and to thededication of ministries of health and national breastfeeding.Although the rate of increase has declined in several regions,in some countries BFHI national committees and nationalprograms, some with support from UNICEF and other part-ners, have preserved the effort. Regions have proceeded atdifferent rates, which may be attributed, in part, to availablefunding and political will. From the data collected it wouldappear that the HIV module was not, as yet, being rapidlyimplemented globally. Revised WHO/UNICEF guidance
may have call for updating; however, the maternity modulewould appear to have been implemented in many regions.
BFHI helped place breastfeeding on the health policyagenda of most countries worldwide.2 Studies show the BFHIapproach to be extremely effective. A review of the evidencefor the Ten Steps conducted by WHO concluded that ‘‘thebasic premise of the Baby-friendly Hospital Initiative, whichrequires all maternity facilities to implement the Ten Steps toSuccessful Breastfeeding, is valid’’12 and that exclusivebreastfeeding will be most effectively increased and sustainedwhen all the 10 Steps are pursued together. However, sub-sequent research has found that implementation of even someof the steps results in significantly improved exclusivebreastfeeding outcomes.13,14 This new evidence may encour-age consideration of Step-wise accreditation, so that all facil-ities, even those that do not wish to address all Ten Steps, maybe stimulated to act.
Limitations and strengths
Program monitoring at the global scale can suffer fromchanging contacts, delayed responses, and reliance on vol-unteer reporting. As a result, it is recognized that thedata provided are a reflection of the global status rather thanan exact report. While the data herein are no exception tothis, they are the only continuous global data available onthis innovative initiative. A major limitation in this assess-ment of global status is the fact that reports of ever-desig-nated facilities in the last decade are only available from 66%of countries, and this limits the conclusions on trends thatcan be made at the global level. In addition, the indicator of‘‘ever-designated’’ does not reflect the current compliance ofhospitals with the Ten Steps, so conclusions of impact cannotbe inferred.
It is also important to note that this article only addressesthe total of hospitals ‘‘ever’’ designated as Baby-Friendly, notthe number currently practicing the Ten Steps. Therefore, itis important to emphasize the need for recertification andcontinuous monitoring of hospital practices. Unless hospitalsare periodically recertified or, alternatively, that the Ten Stepsare included in the standard quality assurance proceduresfor maternity facilities, the practices may gradually deterio-rate, and, consequently, the support for optimal feeding maybe reduced. In the current global situation, in which the
FIG. 2. Total number of hospitals ever-designated ‘‘Baby-Friendly,’’ worldwide.
FIG. 3. Percentage of hospitals ever-designated ‘‘Baby-Friendly,’’ by develop-ing countries, industrialized countries,and worldwide.
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marketing of breastmilk substitutes is so aggressive andreaches so many healthcare workers and hospitals, re-certification remains a vital deterrent to interference withhospital practices.
Finally, to repeat, this article is not based on data collectedfor research purposes, nor can any definitive statement bemade on statistical association. What is presented are chro-nological, ecological correlates, open to discussion and alter-native interpretations.
The results in context
The published studies are consistent in the finding thatimplementation of the Ten Steps and the achievement of BFHIdesignation not only support the proper initiation of breast-feeding in the maternity setting, but also have continuing
impact on duration of EBF. This may be due to impact onmaternal physiology, but may also be due to synergy withcommunity support. Where health professionals supportbreastfeeding, the possibility of disconnect with communityefforts is reduced. For example, if even one child, having beenhospitalized, returns to the village from the hospital havingbeen taken off the breast, the message is effectively sent to allin that village that formula is what the health professionalsconsider better for health. Recent reviews of communityprogramming support the positive results of this synergy.Two recently published reviews of community breastfeedingprojects in developing county settings concluded that com-prehensive programs that include both healthcare systemand the community efforts are more effective than eitheralone.15,16 Considering the temporal relationship of these ef-forts, it is noted that the preexisting programs of health systemsupport result in a noticeably greater impact when a com-munity intervention is introduced.16 An earlier study of thetiming of introduction of BFHI and other breastfeeding sup-port illustrated this temporal association as well.17 This sup-ports the contention that the preexistence of a supportivemedical system, as is created by BFHI or other similar efforts,may be associated with increased impact of community efforts.
The purpose for and challenges to BFHI outlined at In-nocenti + 15 remain relevant. There is an ongoing need todevelop and monitor provision of health worker educationin breastfeeding support and skills, beyond that offered by thein-service BFHI course. However, given that many countriesno longer report activities, there may be a need to addressmessage fatigue18 and create new innovative approaches. Tothis end, increased promulgation of the revised materials mayhelp additional countries, their hospitals, and their associatedtraining centers to consider and offer education in the skillsnecessary to implement the practices needed to supportbreastfeeding in a sustainable manner. Perhaps inclusion ofthe principles and tools of the BFHI into national standards forhealthcare facility accreditation should be considered. This, incontrast with the previous vertical and, often, externallyfunded approach, may be essential for acceleration and sus-tainability of these important maternity care practices. Withrenewed interest in health systems strengthening maternal/neonatal health and community interventions, synergy withrevitalization of support for Ten Steps changes in maternitypractices should be considered and may receive renewednational political and fiscal support.
Conclusions
There is apparent ongoing interest in implementation ofthe Ten Steps and in BFHI, despite the possible reduction inBFHI-specific resource allocation; such reduction may be con-tributing to the reduced rates of reporting. Increased pro-mulgation of the revised BFHI materials and the recognitionthat implementation of even some of the steps can have apositive impact may help additional countries, their hospitals,and their associated training centers to strive to attain theseskills and practices in a sustainable manner. Revitalizationand greater institutionalization into national standards shouldcontribute to the renewed interest in maternal/neonatalhealth and community interventions and attract renewedand strengthened political and fiscal support. In sum, thesepractices have been shown to increase breastfeeding initiation
FIG. 4. Percentage of hospitals ever-designated ‘‘Baby-Friendly’’ by region. Note that data for 1994–1995 wereincomplete and were estimated. In the Americas and theCaribbean (TACRO), it appears that there is a decrease; this isdue to the increase in total number of maternities reportedin the region without a concomitant rate of increase in thenumber of hospital ever-designated as a Baby-Friendly Hos-pital. CEE/CIS, Central and Eastern Europe/Commonwealthof Independent States; EAPRO, East Asia and the Pacific;ESARO, Eastern and Southern Africa; MENA, Middle East/North Africa; WCARO, West and Central Africa.
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and exclusive breastfeeding, with all of its maternal and childhealth and survival impact, and therefore the Ten Steps andBFHI have a vital role as we continue efforts to increase in therates of exclusive breastfeeding worldwide.
Acknowledgments
I would like to start by noting that the BFHI monitoringdata through the 2006 update in this paper were fully sup-ported and collected by and for UNICEF purposes, and arepresented here with permission of UNICEF. In addition, Iwould like to acknowledge the support and cooperation ofUNICEF (www.unicef.org/nutrition/index_breastfeeding.html), especially Dr. Nune Mangasaryan and ChristianeRudert, and their facilitation of contacts with UNICEF Re-gional Nutrition Officers and the generosity of those UNICEFOfficers in countries for giving their time to this purpose. Ialso would like to thank Sarah Amin and the World Alliancefor Breastfeeding Action (www.waba.org.my/) for her en-couragement to undertake this latest update of the BFHI dataand especially to thank all the BFHI committees and UNICEFOfficers who responded to this request for updates. Thepreparation of this article was funded by the Carolina GlobalBreastfeeding Institute Endowment and Operating Funds,which also supported the 2010 BFHI data collection exercise,assisted by in-kind support from UNICEF and BFHI commit-tees worldwide, and World Alliance for Breastfeeding Action.
Disclosure Statement
The author is the Director of the Carolina Global Breast-feeding Institute, which funded this update and analysis. Nocompeting financial interests exist.
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FIG. 5. Percent of infants at all ages, from birth to 6 months of age, exclusively breastfeeding, from cross-sectional surveys.Labels summarize the pattern of BFHI growth, as seen in Figure 4. Note: The 1990 and 2004 estimates are not directlycomparable with the 1995 and 2008 data nor the 2010 data as each published study (see sources below) included differentsubsets of countries (excludes China). In sum, these are point-in-time estimates that may not be entirely comparable, but mayreflect trends. 1990, 2004: This Trend Analysis is based on a subset of 37 countries, covering 60% of the developing world’spopulation. Source: From Innocenti + 15ii. 1995, 2008: Analysis based on a subset of 86 countries with trend data, covering 84percent of births in the developing world. Latin America and the Caribbean were excluded due to insufficient data coverage.Regional trends indicate an increase from 26 to 46 percent, excluding Brazil and Mexico. Source: UNICEF global databases,from Multiple Indicator Cluster Surveys (MICS), Demographic Health Surveys (DHS), and other national surveys, accessed2010 at http://www.childinfo.org 2010: Source: Child Info, accessed June 2012 at http://www.childinfo.org/breastfeeding_progress.html CEE/CIS, Central and Eastern Europe/Commonwealth of Independent States; EAPRO, East Asia and thePacific; ESARO, Eastern and Southern Africa; MENA, Middle East/North Africa; WCARO, West and Central Africa.
GLOBAL REPORT ON BFHI 221
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Address correspondence to:Miriam H. Labbok, M.D., M.P.H., FABM
Carolina Global Breastfeeding InstituteDepartment of Maternal and Child Health
Gillings School of Global Public HealthUniversity of North CarolinaChapel Hill, NC 27599-7445
E-mail: [email protected]
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