Sustaining the Baby-friendly Hospital Initiative Requires All Hands on Deck: Findings from a Two-country Case Study in Malawi and the Kyrgyz Republic

Background: Since the introduction of the Baby-Friendly Hospital Initiative (BFHI) in 1991, improving hospital practices has proved effective; increasing rates of initiation and exclusive breastfeeding and duration. In 2018, WHO and UNICEF updated the BFHI implementation guidance to facilitate the integration of the Ten Steps of successful breastfeeding into the standards of maternity and newborn care. Our objective is to share experiences with BFHI scale up and sustainability from Malawi and the Kyrgyz Republic.

Research Aim/Question: What efforts have governments made to achieve BFHI universal coverage and sustainability?

Methods: We conducted 85 qualitative in-depth interviews of key informants (policy makers, stakeholders, managers, and service providers) from both countries. We analyzed interview and document texts using AtlasTi to apply deductive and inductive codes based on each country’s data.


Results: Respondents reported on health systems strengthening approaches, including operationalized policies and clear responsibilities for implementing and managing BFHI beyond nutrition cadres and using quality improvement to strengthen breastfeeding counseling and support; pre-service training of health professionals; an understanding of motivations at the provider and systems level for effective incentives; monitoring quality of service delivery by health professional organizations and/or other regulatory bodies, and committing national and local financial and material resources to BFHI. Conclusions The nutrition and health sector alone cannot effectively address BFHI scale up and sustainability. To fully integrate BFHI into standards of care requires a multi-sectoral approach, at national and local levels, that also includes education and finance sectors. National policies need to be disseminated throughout the system to support institutionalizing BFHI. The countries have national-level trainers and managers and have strong implementation structures. However, they continue to struggle due to limited monitoring and evaluation, resources, and multi-sectoral engagement.

Publication: The original study was previously published but this presentation is a secondary data analysis looking at a broader aspect of BFHI implementation.

Mukuria-Ashe, A.G, Klein, A., Block, C., Nyambo, K, Uyehara, M., Mtengowadula, G., Nyirongo, G., Makismov, A., Okenov, S., and Alvey, J. 2022. Implementing two national responsibilities of the revised UNICEF/WHO Baby-Friendly Hospital Initiative: A two-country case study. Maternal & Child Nutrition. e13422. https://doi.org/10.1111/mcn.13422

Diversity and Inclusion: The data reported upon is a secondary analysis of an existing project that includes diverse populations and geographic settings. The study reports on the national policy and programmatic level and hence is not indicative of varying sexual orientations, gender identities/expressions, and family structures. References are from a variety of national and local perspectives within the two countries.

This study was also supported by the authors:
Charlotte Block – Technical Advisor, USAID Advancing Nutrition
Malia Uyehara – Project Officer, USAID Advancing Nutrition
Alyssa C. Klein – Food Systems and Nutrition Advisor, USAID Advancing Nutrition