First Steps to the Ten Steps and the Baby Friendly Hospital Initiative

World changing ideas are often conceived at unplanned times and in unexpected places. Such is the case with the Ten Steps and the Baby Friendly Hospital Initiative. The first steps that prepared the way for the Ten Steps and thus for the BFHI began unexpectedly in 1980 at the University of California Medical Center in San Diego (UCSD).

UCSD Medical Center 1980

In 1980, the hospital had a policy of "Modified Rooming-in" which meant that babies were with their mothers except during visiting hours, when doctors made rounds and at night ("mothers need their rest"). A UCSD pediatric faculty member and a Pediatric Nurse Practitioner responsible for normal newborn examinations and for teaching mothers, house officers and medical students about normal newborn care, by chance, attended a series of seminars on the science of lactation and the clinical management of breastfeeding*. The seminar information made it clear that changes were needed at UCSD. Soon after arrangements were made to summarize the seminar information in a series on one hour in-service sessions for the maternity and nursery staff as well as perinatal nutritionists, social workers, the midwifery teaching staff, the pediatric faculty and the neonatologists. The sessions were designed to assess the postpartum care that normal infants and their mothers were receiving at the time and develop recommendations for changes that would be more supportive of lactation physiology and newborn needs.

In 1981 the nursing staff drafted a new policy that included true 24 hour rooming-in, no supplements without a physician's order, unlimited nursing time at the breast, good positioning techniques, regular evaluation of progress of both mother and baby during the hospital stay (then usually 3 days), a follow-up visit soon after discharge, a regular phone call from a member of the nursing staff in 24 to 36 hours after discharge, a written list of indicators of normal breastfeeding progress for parents and a telephone number where the family could reach a knowledgeable care provider seven days a week, 24 hours a day.

In reality and as if often the case, the changes in care procedures were already activated by the time the formal policy was officially approved. All babies, regardless of whether or not the mother had decided to breastfeed, were rooming-in with their mothers 24 hours per day. Nursing staff underwent cross training and were providing family-centered nursing care with one nurse responsible for both mother and baby. Formal evaluation of lactation and breastfeeding progress occurred during every shift. In addition, a Lactation Clinic with a multidisciplinary clinical team was launched. This "first of its kind" service met once a week to provide early routine follow-up care as well as treat problems that arose and of course teach medical and nurse midwifery students as well as house officers from obstetrics, pediatrics and family medicine.

In 1983, Wellstart International was created as an independent nonprofit organization with a dual mission of educating health care professionals and providing service to breastfeeding families. With funding from the United States Agency for International Development (USAID), Wellstart began providing several 4 week long courses in Lactation Management Education each year for multidisciplinary teams of faculty and Ministry of Health leaders from other countries. The 1981 UCSD policy was used as an example of having mother/baby care policies which support the physiology and needs of the newly delivered mother and her newborn infant. Guest faculty were often invited to assist with the Wellstart courses and in 1987, Margaret Kyenkya, the UNICEF Senior Technical Advisor for Nutrition spent a couple of days as a visiting faculty member. The idea of taking the UCSD policy and developing a global model maternity and infant feeding policy was informally discussed over lunch. Upon her return to UNICEF headquarters in New York, Ms Kyenkya began discussions of the idea with other UNICEF colleagues and international experts and with the Nutrition Unit of the World Health Organization. The idea began to take hold. The outcome of these discussions was the 1989 Joint WHO/UNICEF Publication "Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services" in which reference to the Ten Steps first appears.

Representatives of UNICEF, WHO, the Swedish Development Agency (SIDA) and USAID began meeting as an interagency group to map out a global strategy for breastfeeding promotion. This ultimately led to the July 30 - August 1 1990 meeting in Florence Italy at a former foundling home, Spedale degli Innocenti. From this three day meeting of senior health officials representing 31 countries came the Innocenti Declaration and in September 1990, the inclusion of breastfeeding in the nutrition plan of the of the World Summit on Children held at the UN Headquarters in New York.

Early in 1991, UNICEF, under the leadership of James Grant the Executive Director, brought a number of organizations and people together in New York City to discuss strategies for operationalizing the Innocenti Declaration. Wellstart International was invited to participate in these discussions. One of the several outcomes of the meeting came from a small discussion group that focused on hospital practices in which Dr. Audrey Naylor, the co-founder and representative of Wellstart suggested that perhaps some kind of award could be developed for hospitals that actually practiced the Ten Steps. Another outcome of the meeting was the launching of an international grassroots breastfeeding promotion organization, the World Alliance for Breastfeeding Action (WABA).

James Grant was enthusiastic about the ideas and supported launching both outcomes and suggested that the award be called the "Baby Friendly Hospital Award". He and his senior staff went to work laying the ground work. They selected 12 starter countries and worked with regional and country UNICEF offices that served those countries as well as with Ministries of Health.

Wellstart suggested some ideas on what would be needed in order to have a reasonable hospital assessment method that would have international credibility. In June 1991, Margaret Kyenkya arranged to meet in London with Dr. Audrey Naylor, the UCSD pediatric faculty member and Dr. Felicity Savage-King, a well known physician with vast international experience in breastfeeding promotion, to discuss criteria that could be used in developing a global assessment questionnaire. In the fall a few months later with support from UNICEF, Wellstart developed a draft of an international assessment tool, designed an 18 hour course that could be used by hospitals around the world to fulfill the training requirement and planned a training seminar to prepare the first team of master assessors/ trainers.

In February of 1992, a team of 37 professionals who were already knowledgeable about lactation management arrived in San Diego from around the world to spend 10 days together learning to use the new tools as well as train other to use them. Using a train-the-trainers cascade approach, the 37 trainer/assessors returned to their home countries and began launching the BFHI effort.

BFHI Master Assessor/Trainers
The First Wave, February 1992

To further contribute to the global effort, Wellstart also assisted WHO in developing a course for hospital administrators (a bit shorter and with an emphasis on the economic benefits to hospitals) as well as a monitoring and re-evaluation tool.

In 1996, with support from the US Committee for UNICEF (now known as the US Fund for UNICEF), Wellstart also developed the first� BFHI assessment tool and 18 hour course adapted for use in the United States. Following the completion of a pilot test of the tools and designation of the first US Baby Friendly Hospital (Evergreen in Kirkland Washington), an independent nonprofit organization, Baby Friendly USA, was launched to assume ongoing responsibility for assessing and designating hospitals in the United States.

The Baby Friendly Hospital Initiative has proven to be remarkably successful. By 2009 WHO and UNICEF reported that there were over 20,000 hospitals in the world designated as Baby Friendly. Some 86 of these are located in the United States with many more holding certificates of intent to put the Ten Steps into effect for all mothers, babies and families. Never would anyone working with mothers and babies at UCSD in 1980 have imagined such an outcome. As Margaret Meade reminded us many years ago,

"Never doubt that a small group of thoughtful, committed people can change the world.

�Indeed, It is the only thing that ever does".

*Taught in Los Angeles by Kittie Frantz, PNP and Paul Fleiss, MD

**Preparation of the final documents and training seminar had invaluable help from Helen Armstrong, Margaret Kyenkya and Richard Reid from UNICEF and from Ann Brownlee, Mary Kroeger, Janine Schooley, Veronica Valdes, and Ruth Wester as well as Carol Guenther, Monica King and Pat Faucher from Wellstart International.

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