Exclusive breastfeeding, one of the most cost-effective neonatal health interventions, has the potential to save lives of at least 1.5 million children per year globally, yet it remains inadequately recognized [1]. Extensive evidence shows that breastfeeding promotes cognitive development, enhances immunity and reduces the risk of infections among infants. Breastfeeding also protects mothers against diabetes and certain types of cancers such as breast cancer and ovarian cancer [2–4].
The very first few days of a newborn’s life are a critical window for establishing breastfeeding and supporting the mother. The United Nations International Children’s Emergency Fund (UNICEF) and the World Health Organization (WHO) recommend initiating exclusive breastfeeding within the first hour of birth, continuing exclusively for the first 6 months, and then up to two years of age with complementary feeding [5].
Healthcare facilities play a crucial role in providing timely infant and maternal support. In response, UNICEF and WHO launched the Baby Friendly Hospital Initiative (BFHI) in 1991 to support, protect, and promote breastfeeding worldwide [2]. Healthcare facilities are recognized as baby-friendly by implementing the “Ten Steps to Successful Breastfeeding”, adhering to the WHO Code of Marketing of Breast-milk Substitute and the World Health Assembly (WHA) resolutions [2, 6].
WHO and UNICEF emphasize the significant role of BFHI in the improvement of breastfeeding adherence in the Middle East and North Africa (MENA) countries [7]. Executing the ten steps of the BFHI reflects positively on the rates of exclusive breastfeeding, as well as total breastfeeding duration and initiation. However, several challenges exist for implementing and sustaining the BFHI within healthcare facilities, especially in developing and underdeveloped countries [8]. For instance, infant formula industries were known to pressure hospitals and provide financial incentives to healthcare professionals to promote infant formula products. Other challenges include improper hospital infrastructure and medicalization of childbirth, all which interfere with baby-friendly practices [7, 9]. Improper implementation of the BFHI leads to suboptimal breastfeeding which contributes to malnutrition [7].
Despite the WHA’ s aim to achieve a 50% global target rate of exclusive breastfeeding by 2025, this target is far from reach, as breastfeeding rates remain suboptimal, especially within MENA region [1, 10]. Alzaheb et al. (2017) shows a 34% average prevalence of newborns breastfed within the first hour of birth, and only 20.5% were exclusively breastfed for 6 months in several Arab countries including Saudi Arabia, Egypt, Kuwait, the United Arab Emirates, Qatar, Lebanon, and Syria. [11]. According to the reported global breastfeeding scorecard 2022 in the MENA countries, an average of 22% of infants were born in baby-friendly health facilities [12]. The scorecard reveals the lowest rate of exclusive breastfeeding in Comoros (11%) while the highest rate reported in Sudan (55%), among the MENA region. [12]. Although Lebanon appears to have high breastfeeding initiation rates (73%), exclusive breastfeeding prevalence remains low (18.5%) [3]
Breastfeeding rates are influenced by several determinants, including demographic factors, environmental factors such as community and political support, the knowledge of healthcare professionals, as well as prevailing cultural attitudes and misconceptions [13, 14]. The benefits of breastfeeding are especially crucial for countries in the MENA region, where the maternal and neonatal mortality as well as malnutrition are high [15]. Countries suffering from malnutrition and countries with complex emergency situations were found to have improper implementation of the BFHI [7]. No emergency preparedness plan yet exists that protects the BFHI for ensuring maternal and infant survival [7].
Strengthening and expanding the BFHI at the healthcare system level provides hospitals and healthcare facilities with the capacity to protect exclusive breastfeeding and support the mother. Aboul-Enein et al. (2023) show that the BFHI is an effective large-scale initiative for maximizing the positive impacts of breastfeeding educational programs through individual and community-based interventions [16]. This includes healthcare-professional trainings, capacity building of health staff, and multiple stakeholder engagements. Furthermore, educating both the mother and healthcare professionals can enhance the breastfeeding attitude, knowledge and practices [16]. Government action is necessary through national political commitment as well as monitoring in revitalizing the BFHI and ensuring sustainability [7, 16].
For more information regarding BFHI and its implementation, check the below resources extracted from WHO and UNICEF:
Implementation Guidance:
https://www.who.int/publications/i/item/9789241513807
Competency verification toolkit:
https://www.who.int/publications/i/item/9789240008854
The Ten steps to Successful Breastfeeding Infographic: https://www.unicef.org/media/95186/file/Ten%20steps%20to%20successful%20breastfeeding%20infographic.pdf
Baby-friendly Hospital Initiative training course for maternity staff:
https://www.who.int/publications/i/item/9789240008915
References:
[1] N. Al-Nuaimi, G. Katende, and J. Arulappan, “Breastfeeding Trends and Determinants: Implications and recommendations for Gulf Cooperation Council countries,” (in eng), Sultan Qaboos Univ Med J, vol. 17, no. 2, pp. e155-e161, May 2017, doi: 10.18295/squmj.2016.17.02.004.
[2] World Health Organization and United Nations Children’s Fund (UNICEF), “Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: implementing the revised Baby-friendly Hospital Initiative,” ISBN: 978-92-4-151380-7, 2018. [Online]. Available: https://www.who.int/publications/i/item/9789241513807
[3] F. Naja et al., “Prenatal breastfeeding knowledge, attitude and intention, and their associations with feeding practices during the first six months of life: a cohort study in Lebanon and Qatar,” International Breastfeeding Journal, vol. 17, no. 1, p. 15, 2022, doi: 10.1186/s13006-022-00456-x.
[4] A. C. Masi and C. J. Stewart, “Role of breastfeeding in disease prevention,” (in eng), Microb Biotechnol, vol. 17, no. 7, p. e14520, Jul 2024, doi: 10.1111/1751-7915.14520.
[5] World Health Organization. “Infant and Young Child Feeding.” https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding (accessed.
[6] World Health Organization. “International Code of Marketing of Breast-Milk Substitutes.” https://www.who.int/publications/i/item/9241541601 (accessed.
[7] A. Al-Jawaldeh and A. Abul-Fadl, “Assessment of the Baby Friendly Hospital Initiative Implementation in the Eastern Mediterranean Region,” Children, vol. 5, no. 3, p. 41, 2018. [Online]. Available: https://www.mdpi.com/2227-9067/5/3/41.
[8] R. Pérez-Escamilla, J. L. Martinez, and S. Segura-Pérez, “Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review,” (in eng), Matern Child Nutr, vol. 12, no. 3, pp. 402-17, Jul 2016, doi: 10.1111/mcn.12294.
[9] C. Akik, “Breastfeeding in Lebanon: barriers and policy dynamics,” 2014, doi: DOI: 10.17037/PUBS.02019574.
[10] World Health Organization. “Global nutrition targets 2025: policy brief series.” https://www.who.int/teams/nutrition-and-food-safety/global-targets-2025 (accessed.
[11] R. A. Alzaheb, “A Review of the Factors Associated With the Timely Initiation of Breastfeeding and Exclusive Breastfeeding in the Middle East,” Clinical Medicine Insights: Pediatrics, vol. 11, p. 1179556517748912, 2017, doi: 10.1177/1179556517748912.
[12] Global Breastfeeding Collective. “Global Breastfeeding Scorecard.” https://www.globalbreastfeedingcollective.org/global-breastfeeding-scorecard (accessed.
[13] N. C. Rollins et al., “Why invest, and what it will take to improve breastfeeding practices?,” The Lancet, vol. 387, no. 10017, pp. 491-504, 2016/01/30/ 2016, doi: https://doi.org/10.1016/S0140-6736(15)01044-2.
[14] H. Oueidat, L. Charafeddine, H. Nimer, H. Hussein, and M. Nabulsi, “Knowledge and attitudes of Lebanese women towards Baby Friendly Hospital Initiative practices,” (in English), PloS one, vol. 15, no. 9, pp. e0238730-e0238730, 2020, doi: 10.1371/journal.pone.0238730.
[15] L. Nasreddine, J. J. Ayoub, and A. Al Jawaldeh, “Review of the nutrition situation in the Eastern Mediterranean Region,” (in English), Eastern Mediterranean Health Journal, vol. 24, no. 1, pp. 77-91, 2018, doi: https://doi.org/10.26719/2018.24.1.77.
[16] B. H. Aboul-Enein, E. Dodge, N. Benajiba, and R. M. Mabry, “Interventions and Programs to Promote Breastfeeding in Arabic-Speaking Countries: A Scoping Review,” Maternal and Child Health Journal, vol. 27, no. 5, pp. 774-794, 2023/05/01 2023, doi: 10.1007/s10995-023-03595-7.
