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Nov 2018
 Implementation Guidance on the Revised Baby-friendly Hospital Initiative (WHO & UNICEF, 2018)

Dr Patricia IP
Chairperson, Committee on Designation of Baby-friendly Health Facilities
Vice Chairperson, Baby Friendly Hospital Initiative Hong Kong Association

Breastfeeding matters, no less now than in 1991, when WHO / UNICEF launched the Baby-friendly Hospital Initiative (BFHI). With the scaling up of breastfeeding, there could be 820,000 less under-5 deaths of children and 20,000 less deaths of mothers from breast cancer each year1 and USD 300 million added to the global economy.2 The contribution of breastfeeding to the reduction of non-communicable diseases is well recognised1 and the environmental impact of tons of carbon dioxide emission from formula feeding cannot be ignored.3 Fundamentally, enabling a baby to be breastfed realises a child’s right to survival, development, protection and participation.  Both the child has the right to the highest standard of health and the mother the right to ample support to carry out her informed choice on infant feeding. 

On this basis, WHO reviewed the evidence of the Ten Steps to Successful Breastfeeding and the implementation of BFHI4 recently, as it was estimated, even in 2016, only 10% of births takes place in designated baby-friendly hospitals (BFH) and many designated hospitals have not been revalidated. A number of recommendations emerged from the review, leading to the “Implementation Guidance on Protecting, Promoting and Supporting Breastfeeding in Faciliies providing Maternity and Newborn Services: the Revised Baby-friendly Hospital Initiative” being published in 2018.5

Essence of the Revised 2018 Implementation Guidance  
Overall, descriptions of the revised 2018 version tend to be more specific, outcome-oriented and supportive for mothers. The following table shows a comparison between the 2018 version of the Ten Steps to Successful Breastfeeding (Ten Steps) and the last revision issued in 2009. 


2018 Version

2009 Version


a.   Comply fully with the International Code of  Marketing of Breast-milk Substitutes and relevant WHA resolutions.

b.   Have a written infant feeding policy that  is routinely communicated to staff and  parents.

c.   Establish ongoing monitoring and data management.

Have a written breastfeeding policy that is routinely communicated to all health care staff



Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding.

Train all health care staff in skills necessary to implement the policy


Discuss the importance and management of breastfeeding with pregnant women and their families.

Inform all pregnant women about the benefits and management of breastfeeding.


Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.


Help mothers initiate breastfeeding within a half-hour of birth (now interpreted as: Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour. Encourage mothers to recognize when their babies are ready to breastfeed and offer help if needed.)


Support mothers to initiate and maintain breastfeeding and manage common difficulties.


Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.


Do not provide breastfed newborns any food or fluids other than breastmilk, unless medically indicated.

Give newborn infants no food or drink other than breast milk, unless medically indicated.


Enable mothers and their infants to remain together and to practice rooming-in 24 hours a day.

Practice rooming-in – allow mothers and infants to remain together – 24 hours a day.


Support mothers to recognize and respond to their infants’ cues for feeding.

Encourage breastfeeding on demand.


Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.


Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.


Coordinate discharge so that parents and their families have timely access to ongoing support and care.


Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

The following table displays other differences between the two versions. 


2018 Version

2009 Version


All newborns including small, sick, preterm

Healthy full term infants


Mother-friendly care

Expectedalthough not part of BFHI

Optional module, encouraged


Management according to health authority recommendation

Optional module


Scoring in BFH assessment

80% or above


Mostly 80%, others 75%, 70%, 50% or above

Transition to 2018 Implementation Guidance in Hong Kong
As the revised Ten Steps are clearer, health facilities are recommended to adopt the revised wordings in the near future, if not immediately. Training materials should be progressively aligned. On the other hand, BFHI is a relatively new programme in Hong Kong. Many hospitals are still working towards the Ten Steps in relation to healthy term infants. It would be a major step if all small, sick and preterm newborns are included in the programme immediately although this would be the eventual goal.

WHO has reminded health care providers that BFHI is not to be implemented in isolation and assumes other related practices e.g. “WHO recommendations: intrapartum care for a positive childbirth experience”6 and “Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice”7 are being implemented as well. Hence mother-friendly care, previously an optional module, is now an expected practice. Local hospitals are thus strongly encouraged to practise mother-friendly care especially when the hospital has included this in the hospital policy.

The revised BFHI implementation guidance requires the attainment of at least 80% for the various standards. This has already been the requirement of the internal audit tools of the UK UNICEF Baby-friendly Initiative adopted by local hospitals in the BFHI programme. This requirement would therefore be followed in the external assessment of new applicants to the programme. As is the current practice, there is no requirement for a specific breastfeeding rate prior to an application.

The following table shows the recommended transition of the Hong Kong BFHI programme to the 2018 Guidance.

2018 Guidance

Way forward for Hong Kong

New wordings of the Ten Steps

All new applicants to BFHI programme

Current participants – adoption is voluntary

Preterm, small and sick newborns

BFHI practices encouraged

Separate assessment in the future

Mother-friendly care

Strongly encouraged

If stated in hospital policy, need to justify any deviation from the policy

Assessment scoring of 80% or above

All new applicants and revalidation

(Continue to exclude requirement of 80% exclusive breastmilk feeding)

Related Initiatives
The 2018 Guidance encourages other breastfeeding support initiatives outside the hospital setting. Baby Friendly Hospital Initiative Hong Kong Association (BFHIHKA) will continue to encourage and facilitate health facilities in the community to achieve the relevant baby-friendly standards. 

The new WHO guidance brings a better understanding to the BFHI and the evidence-based practices in maternal and neonatal care that support breastfeeding. BFHIHKA hopes the progressive approach tailored to the local situation would ease the transition process.


Victora CG, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016; 387:475-90.

Rollins NC, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016:387:491-504.

Dadhich JP, et al. Report on carbon footprints due to milk formula: a study from selected countries of the Asia-Pacific Region. Dehli: BPNI/IBFAN Asia; 2016
http://ibfan.org/docs/Carbon-Footprints-Due-to-Milk-Formula.pdf accessed 12 October 2018

Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. Geneva: World Health Organization; 2017
http://www.who.int/nutrition/publications/guidelines/breastfeeding-facilities-maternity-newborn/en/  accessed 12 October 2018

Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-friendly hospital initiative implementation guidance:. Geneva: World Health Organization; 2018
accessed 12 October 2018

WHO recommendations: intrapartum care for a positive childbirth experience. WHO; 2018
accessed 12 October 2018

Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. WHO, United Nations Population Fund, UNICEF; 2015
accessed 12 October 2018

Editor-in-Chief: Dr Shirley Leung
Editorial Team: Ms Christine Lam, Ms Sing Chu, Ms Georgiana Cheung, M Ms Iris Lam, Ms Grace Ma, Ms Candice Chin

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