Lactation Matters

2018 Baby-Friendly Hospital Initiative (BFHI) Revised Implementation Guidance

The document commonly known as the “Ten Steps” has recently been updated. ILCA has been actively advocating on behalf of the lactation community throughout the revision process. Below is a open letter to the community with an update on the revisions. ILCA would like to extend significant gratitude to the volunteers who have devoted many, many hours to this effort.

Dear Colleagues,

After months of thoughtful and productive discussion with our five global breastfeeding promotion organizations, on April 11, 2018, the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) released the final version of the Implementation Guidance: Protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-friendly Hospital Initiative 2018. The final document is highly responsive to the recommendations made by our organizations, and we congratulate the WHO and UNICEF on a successful launch.

We strongly agree with the WHO and UNICEF that “breastfeeding is a vital component of realizing every child’s right to the highest attainable standard of health, while respecting every mother’s right to make an informed decision about how to feed her baby, based on complete, evidence-based information, free from commercial interests, and the necessary support to enable her to carry out her decision.”

We also concur that “the first few hours and days of a newborn’s life are a critical window for establishing lactation and providing mothers with the support they need to breastfeed successfully” and that the “core purpose of the Baby-Friendly Hospital Initiative (BFHI) is to ensure that mothers and newborns receive timely and appropriate care before and during their stay in a facility providing maternity and newborn services, to enable the establishment of optimal feeding of newborns, which promotes their health and development.”

We applaud the full application of the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly Resolutions (the International Code), comprehensive, evidence-based infant feeding policies and ongoing internal monitoring of adherence to relevant clinical practices being incorporated into Step One.

We stand united with the WHO and UNICEF on the goal of scaling up to universal BFHI coverage and ensuring its sustainability over time.

BACKGROUND

Motivated by deep concerns about the uneven and relatively low global adoption of the BFHI, the WHO and UNICEF undertook the important tasks of evaluating the strengths and weaknesses of the initiative and charting a course to revitalize both the overall initiative and the global standards. It was an enormous undertaking.

An initial draft of their new proposed approach was released for public comment on October 11, 2017.  Our five organizations came together and, at the invitation of the WHO and UNICEF, shared our collective expertise and worked with them to recommend changes in some areas that were not fully addressed in the proposal and further develop the guidance.

We would like to thank the WHO and UNICEF for their openness and willingness to engage in discussions and undertake the extra effort required to incorporate our recommendations.  During the 6-month period of meetings, all parties worked together with the mutual goal of strengthening the guidance to empower countries to scale up to universal adoption.

HIGHLIGHTS OF KEY HIGH-LEVEL RECOMMENDATIONS

  • Governments should become involved in the national implementation of the BFHI and should undertake efforts to integrate international standards into national systems.
  • Professional organizations responsible for pre-service education should incorporate the evidence and practices embodied in the Ten Steps to Successful Breastfeeding (the Ten Steps) into their curricula.
  • Efforts should be undertaken to draw public attention to the importance of breastfeeding, the risks of formulas and the practices that will help to protect, promote and support breastfeeding.
  • Efforts should be undertaken to protect breastfeeding, families and staff from commercial marketing and unethical pressures.
  • BFHI should be integrated into other interventions, existing international and/or national programs, and coordinated with efforts to support breastfeeding in communities and the workplace.
  • For those countries that currently have a well-functioning designation program able to reach the majority of facilities providing maternity and newborn services nationwide, this new guidance should not be viewed as a reason to discontinue a successful program.

HIGHLIGHTS OF KEY COMPONENTS OF THE GUIDANCE

  • Stresses the importance of exclusive breastfeeding for six months to provide the nurturing, nutrients and energy needed for physical and neurological growth and development.
  • Includes a clear set of global criteria, with the option to tailor for applicability to national standards.
  • Retains the Ten Steps in their original order and subject matter. Includes wording changes that are more generalized and designed to allow for the future incorporation of new and/or updated evidence. Explains the intent of each of the steps and offers clear guidance for their implementation.
  • Acknowledges the contribution of each of the ten steps to improving the support for breastfeeding, and stresses the need for all ten steps to be implemented as a package in order to attain an optimal impact on breastfeeding practices.
  • Provides updated guidance for the safe implementation of practices and monitoring of patients. Reminds health care providers of the importance of individualized attention and care.
  • Describes the importance of mother-friendly birth practices and the impact of birth practices on breastfeeding. Stresses the importance of healthcare professionals being knowledgeable about those practices and their responsibility for educating mothers. Refers them to other WHO guidelines for more details on the specific practices.
  • Stresses the importance of breastfeeding and/or breast milk feeding for all infants cared for in a facility by including some guidelines, indicators and standards for providing breastfeeding support for preterm infants in addition to the guidelines, indicators and standards that have been traditionally included for healthy term infants.
  • Sets a mandate for the evidence and practices embodied in the Ten Steps to be included in health care pre-service curricula while retaining the need to continue with in-service education until this is accomplished and several classes have graduated and entered into practice.
  • Explains the responsibility of healthcare facilities and professionals for implementing the International Code and places it prominently in Step 1, setting the stage for the International Code to be embodied in all aspects of patient care.
  • Stresses the importance of and proposes systems for monitoring and sustaining the practices.
  • Provides clearly defined indicators that are easy to assess and will allow for comparisons between countries. Retains all indicators at the 80% level.
  • Acknowledges the importance of public recognition, such as accreditation, as a key driver for change. Points to the need for external evaluation or assessment as one of the key principles of quality improvement and acknowledges the process of becoming Baby-friendly as transformative, with impacts pertaining to the entire environment around infant feeding.  This included the care being more patient centered; staff attitudes and skill levels about infant feeding improving dramatically; the use of infant formula and newborn nurseries being significantly reduced. States that the quality of care for breastfeeding clearly improved in facilities designated as “baby-friendly”.
  • Offers robust guidance for additional quality improvement options for countries where the traditional accreditation options are beyond reach.
  • Reinforces the role of facilities providing maternity and newborn services of identifying appropriate community resources for continued and consistent breastfeeding support that is culturally and socially sensitive to the needs of families. Reminds facilities they have a responsibility to engage with the surrounding community to enhance such resources.

 

Call to Action:

Given the responsiveness of this document to the concerns raised around the initial 2017 draft, we now call upon all those working with families on infant and young child feeding to band together, support its goals, and work within your countries to implement it in the most effective manner.

Next Steps:

We are working to ensure that a provision is included in a resolution for the upcoming World Health Assembly (WHA) to request the Director General of WHO to work in collaboration with UNICEF to develop tools for training, monitoring, and advocacy on the Baby-Friendly Hospital Initiative to assist Member States with implementation. We will continue to monitor the progress of the resolution, the development of tools, and implementation of the BFHI guidance.

Thank you.

 

Sincerely,

Trish MacEnroe
Coordinator
Baby-Friendly Hospital Initiative Network of Industrialized Nations, Central and Eastern European Nations and Independent States (BFHI Network)

Elisabeth Sterken
Co-chair IBFAN Global Council
International Baby Food Action Network (IBFAN)

Michele Griswold
President
International Lactation Consultant Association (ILCA)

Ann Calandro
Chair
La Leche League International (LLLI)

Felicity Savage
Chairperson
World Alliance for Breastfeeding Action (WABA)

 

Additional translations of this blog post are available in Spanish and French.

Iniciativa Hospital Amigo De Los Niños Y Las Niñas 2018 (IHAN) Guia Revisada De Implementacion

Estimados colegas,

Tras meses de profundo y productivo debate entre nuestras cinco organizaciones mundiales de promoción de la lactancia materna, el 11 de abril de 2018, la Organización Mundial de la Salud (OMS) y el Fondo de las Naciones Unidas para la Infancia (UNICEF) publicaron la versión final de la Guía de Implementación: Proteger, promover y apoyar la lactancia materna en instituciones que brindan servicios de maternidad y neonatología: la Iniciativa Hospital Amigo de los Niños y las Niñas 2018 revisada. El documento final responde en gran medida a las recomendaciones formuladas por nuestras organizaciones y felicitamos a la OMS y al UNICEF por el éxito de su lanzamiento.

Estamos completamente de acuerdo con la OMS y UNICEF en que “La lactancia materna es un componente vital para hacer realidad el derecho de todos los niños y niñas a gozar del más alto nivel posible de salud, al tiempo que se respeta el derecho de todas las madres a tomar una decisión informada sobre cómo alimentar a su bebé, basada en información completa y basada en la evidencia, libre de intereses comerciales, y el apoyo necesario para que pueda llevar a cabo su decisión”.

También estamos de acuerdo en que “las primeras horas y días en la vida de un recién nacido son una ventana crítica para establecer la lactancia y proporcionar a las madres el apoyo que necesitan para amamantar con éxito” y que “el propósito central de la Iniciativa Hospital Amigo de los niños y las niñas (IHAN) es asegurar que las madres y los recién nacidos reciban atención oportuna y apropiada antes y durante su estancia en una institución que proporciona servicios de maternidad y neonatología, que permita el establecimiento de una alimentación óptima para los recién nacidos, lo que promueve su salud y desarrollo.”

Aplaudimos la plena aplicación del Código Internacional de Comercialización de Sucedáneos de Leche Materna y Resoluciones relacionadas de la Asamblea Mundial de la Salud (el Código Internacional), la incorporación en el Primer Paso de políticas integrales de alimentación infantil basadas en la evidencia y la monitorización continuada de la observancia de las prácticas clínicas relevantes.

Nos alineamos con OMS y UNICEF en su objetivo de ampliar a universal la cobertura de la IHAN para las instituciones de salud materno infantil y garantizar su sostenibilidad en el tiempo.

ANTECEDENTES

Motivados por la profunda preocupación ante la adopción desigual y relativamente baja de la IHAN en todo el mundo, la OMS y el UNICEF emprendieron la importante tarea de evaluar las fortalezas y debilidades de la IHAN y trazar un rumbo para revitalizar tanto la iniciativa como los estándares globales. Una tarea ingente.

l 11 de octubre de 2017 se abrió un periodo de comentario público sobre el primer borrador con propuestas de un nuevo enfoque. Nuestras cinco organizaciones se reunieron y atendiendo a la invitación de la OMS y el UNICEF, compartieron experiencia y trabajaron conjuntamente para aportar a un mayor desarrollo de la guía y recomendar cambios en determinadas áreas no abordadas plenamente por la propuesta.

Deseamos agradecer a la OMS y al UNICEF su apertura y disposición para el debate y haber realizado el necesario esfuerzo adicional para incorporar nuestras recomendaciones. Durante el período de seis meses en que se celebraron las reuniones, todas las partes trabajaron conjuntamente con el objetivo común de fortalecer la guía para empoderar a los países hasta alcanzar la adopción universal.

RECOMENDACIONES PRINCIPALES: ASPECTOS DESTACADOS.

  • Los gobiernos deben involucrarse en la aplicación nacional de la IHAN y realizar esfuerzos para integrar los Criterios Globales en los sistemas nacionales de salud.
  • Las organizaciones profesionales responsables de la educación pre-grado deben incorporar en sus planes de estudio las evidencias y prácticas concernientes a los Diez Pasos para una feliz Lactancia Materna (los Diez Pasos).
  • Se deben realizar esfuerzos para atraer a la atención pública la importancia de la lactancia materna, los riesgos de las fórmulas y las prácticas que ayudaran a proteger, promover y apoyar la lactancia materna.
  • Se deben realizar esfuerzos para proteger a la lactancia materna, las familias y los trabajadores de las presión y las prácticas no éticas de la industria.
  • La IHAN debe ser integrada en otras intervenciones y programas internacionales y/o nacionales ya existentes, y coordinarla con otros esfuerzos de apoyo a la lactancia materna en las comunidades y lugares de trabajo.
  • En aquellos países que actualmente cuentan con un programa de acreditación que funciona correctamente y capaz de llegar a la mayoría de los centros que prestan servicios de maternidad y neonatología del país, esta nueva guía no debe ser considerada una razón para interrumpir un programa con éxito.

GUIA DE IMPLEMENTACION: ASPECTOS DESTACADOS DE LAS PRINCIPALES RECOMENDACIONES

  • Destaca la importancia de la lactancia materna exclusiva durante 6 meses para proporcionar la nutrición y la energía necesarios para el crecimiento y el desarrollo físico y neurológico.
  • Incluye un conjunto claro de criterios globales, con la opción de adaptar la aplicabilidad a las normas nacionales.
  • Mantiene los Diez Pasos en su orden y tema original. Incluye cambios de redacción más generalizados y diseñados para permitir la incorporación futura de pruebas nuevas y/o actualizadas. Explica la intención de cada uno de los pasos y ofrece una guía clara para su implementación.
  • Reconoce la contribución de cada uno de los Diez Pasos a la mejora del apoyo a la lactancia materna, y subraya la necesidad de que para lograr un impacto óptimo en las prácticas de lactancia materna, los Diez Pasos se implementen como un todo.
  • Proporciona una guía actualizada para la implementación segura de las prácticas y el seguimiento de los pacientes. Recuerda a los proveedores de salud la importancia de la atención y el cuidado individualizados.
  • Describe la importancia de las prácticas de parto amigables con la madre y el impacto de las mismas sobre la lactancia materna. Destaca la importancia de que los profesionales de la salud conozcan estas prácticas y su responsabilidad en la educación de las madres. Les remite a otras guías de la OMS para más detalles sobre las prácticas específicas.
  • Destaca la importancia de la lactancia materna y/o la leche materna para todos los lactantes atendidos en una institución, mediante la inclusión de directrices, indicadores y normas para la prestación de apoyo a la lactancia materna de los lactantes prematuros, además de las directrices, indicadores y normas que tradicionalmente se han incluido para los lactantes a término sanos.
  • Establece un mandato para que la evidencia y las prácticas incorporadas en los Diez Pasos sean incluidas en los planes de estudio de pre-grado de las profesiones sanitarias, manteniendo la necesidad de continuar con la educación post grado hasta que esto se logre y varias generaciones se hayan graduado y estén trabajando.
  • Explica la responsabilidad de las instituciones de salud y de los profesionales de la salud en la implementación del Código Internacional y lo coloca en un lugar pre eminente en el Paso 1, sentando las bases para que el Código Internacional se incorpore en todos los aspectos de la atención al paciente.
  • Propone sistemas para monitorizar y asegurar la sostenibilidad de las prácticas y destaca la importancia de las mismas.
  • Proporciona indicadores claramente definidos fáciles de evaluar y permitirán comparaciones entre países. Mantiene todos los indicadores al nivel del 80%.
  • Reconoce la importancia de medidas de reconocimiento público, como la acreditación, como motor clave del cambio. Señala la necesidad de una evaluación o valoración externa como uno de los principios clave de la mejora de la calidad y reconoce que el proceso de convertirse en “IHAN” es transformador, con repercusiones en todo el entorno de la alimentación infantil. Esto incluye que la atención se centra más en el paciente; que las actitudes y los niveles de destreza del personal con respecto a la alimentación infantil mejoran drásticamente; y que se reduzca significativamente el uso de fórmulas para lactantes y de las “nido” para recién nacidos. Afirma que la calidad de la atención de la lactancia materna mejora significativamente en las instituciones IHAN.
  • Ofrece una guía sólida para opciones adicionales de mejora de la calidad para países donde las opciones tradicionales de acreditación están fuera de alcance.
  • Refuerza el papel de las instalaciones que proporcionan servicios de maternidad y neonatología en la identificación de recursos comunitarios apropiados para un apoyo continuo y consistente a la lactancia materna que sea cultural y socialmente sensible a las necesidades de las familias. Recuerda a los establecimientos que tienen la responsabilidad de involucrarse con la comunidad para mejorar dichos recursos.

Llamada a la acción:

Dada la receptividad de este documento a las preocupaciones planteadas en torno al borrador inicial de 2017, hacemos ahora un llamamiento a todos los involucrados en la alimentación de lactantes y niños y niñas pequeños, que trabajan con las familias, para que se unidos, apoyen sus objetivos y trabajen dentro de sus países para implementarlo de la manera más eficaz posible.

Siguientes Pasos:

Estamos trabajando para asegurar que se incluya una disposición en una resolución de la próxima Asamblea Mundial de la Salud, que solicite al Director General de la OMS que trabaje en colaboración con UNICEF para desarrollar herramientas para la capacitación, el monitoreo y la promoción de la Iniciativa de Hospitales Amigos de los Niños que ayuden a los Estados Miembros con la implementación. Continuaremos monitorizando el progreso de la resolución, el desarrollo de herramientas y la implementación de la guía IHAN.

Gracias.

Sinceramente,

Trish MacEnroe
Coordinadora
Red IHAN de las Naciones Industrializadas, las Naciones de Europa Central y Oriental y los Estados Independientes (BFHI network)

Elisabeth Sterken
Copresidenta del Consejo Mundial de IBFAN
Red Internacional de Acción para la Alimentación Infantil (IBFAN)

Michele Griswold
Presidenta
Asociación Internacional de Consultores en Lactancia (ILCA)

Ann Calandro
Presidenta
Liga Internacional de la Leche (LLLI)

Felicity Savage
Presidenta
Alianza Mundial para la Acción pro Lactancia Materna (WABA)

Las traducciones adicionales de esta comunicación están disponibles en inglés francés.

 

 

2018 Initiative Hôpitaux Amis Des Bébés (IHAB) Nouvelles Lignes Directrices

Chères collègues,

Après plusieurs mois de réflexions et de discussions productives avec nos cinq organisations internationales en promotion de l’allaitement, l’OMS et l’UNICEF ont publié la version finale des lignes directrices pour les IHAB, le 11 avril 2018, Implementation Guidance: Protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-friendly Hospital Initiative 2018. Le document final reflète très clairement les recommandations apportées par nos cinq organisations et nous félicitons l’OMS et l’UNICEF pour cette publication réussie.

Nous sommes entièrement en accord avec l’OMS et l’UNICEF que “l’allaitement représente un élément essentiel pour que soit reconnu pour tout enfant le droit fondamental au plus haut niveau de santé, tout en respectant le droit de la mère de prendre une décision éclairée sur la façon de nourrir son enfant. Cette décision doit être prise en se fiant à une information complète, basée sur des données probantes et libre de tout intérêt commercial. Le soutien nécessaire doit aussi être présent pour l’aider à actualiser sa décision.”

Nous sommes aussi de l’avis de l’OMS et de l’UNICEF lorsqu’ils affirment que “les premières heures et les premiers jours d’un nouveau-né sont critiques pour l’initiation de la lactation et pour soutenir les mères à allaiter avec succès” et que “le but de l’IHAB est de s’assurer que les mères et les nouveau-nés reçoivent les soins appropriés et en temps requis, avant et pendant leur séjour en maternité, en vue de faciliter la meilleure nutrition possible pour favoriser la santé et le développement des bébés.”

Nous nous réjouissons du fait que la condition 1 comprend dorénavant l’application complète du Code international de commercialisation des substituts du lait maternel (le Code international) et les résolutions subséquentes de l’Assemblée mondiale de la santé (AMS) qui le concernent, de même que des politiques complètes de nutrition de l’enfant basées sur des données probantes et le monitoring des pratiques cliniques liées à ces politiques.

Nous unissons nos voix à celles de l’OMS et de l’UNICEF pour que l’IHAB soit implantée partout dans le monde et que sa durabilité soit assurée au fil du temps.

CONTEXTE

Préoccupés par l’adoption inégale et assez faible de l’IHAB au niveau mondial, l’OMS et l’UNICEF ont entrepris d’évaluer les forces et les faiblesses de l’Initiative et de la revitaliser ainsi que les critères internationaux qui s’y rattachent. C’était une lourde tâche.

Des lignes directrices ont d’abord été proposées pour critique publique en octobre 2017. Nos cinq organisations se sont réunies et, à l’invitation de l’OMS et l’UNICEF, ont partagé leurs expertises en vue de bonifier ce premier jet dans lequel certains aspects n’avaient pas été touchés en profondeur.

Nous désirons remercier l’OMS et l’UNICEF pour leur ouverture et leur intérêt à poursuivre les discussions avec nous et à intégrer nos recommandations dans ce premier jet. Nous nous sommes attelés à la tâche tous ensemble durant 6 mois pour renforcer les lignes directrices en vue de permettre aux pays d’évoluer vers une adoption universelle de l’IHAB.

Traduction libre par Louise Dumas, Comité canadien pour l’allaitement; texte original en anglais “2018 Baby-Friendly Hospital Initiative (BFHI) Revised Implementation Guidance” du 11 avril 2018.

FAITS SAILLANTS DES RECOMMANDATIONS PRINCIPALES

Les gouvernements doivent s’impliquer dans l’implantation nationale de l’IHAB en plus de s’efforcer à intégrer les critères internationaux dans leurs systèmes nationaux.

Les responsables de la formation initiale des professionnels de la santé doivent intégrer dans leur curricula les évidences et la pratiques cliniques sous-jacentes aux Dix conditions pour le succès de l’allaitement (les Dix conditions).

Il faut attirer l’attention du public quant à l’importance de l’allaitement, des risques des substituts du lait maternel et des pratiques qui aident la protection, l’encouragement et le soutien à l’allaitement. Des efforts doivent être entrepris pour protéger l’allaitement, les familles et les travailleurs de la santé des pressions et de la commercialisation non-éthiques exercées par les compagnies de substituts du lait maternel. L’IHAB doit être intégrée dans d’autres interventions et programmes nationaux ou internationaux, en vue de coordonner les efforts pour le soutien de l’allaitement dans les communautés et les lieux de travail.

Les pays ayant développé un programme de reconnaissance et de certification pour tous les établissements de santé prodiguant des soins et services périnatals n’ont pas à cesser ces activités si elles sont productives. Ce n’est pas le but des lignes directrices actuelles.

FAITS SAILLANTS EN REGARD DES PRINCIPAUX ÉLÉMENTS DES LIGNES DIRECTRICES

Mettent l’accent sur l’exclusivité de l’allaitement pour les 6 premiers mois en vue de prodiguer à la fois les soins, les nutriments et l’énergie nécessaires à une croissance et à un développement physique et neurologique optimal.

Incluent une liste de critères internationaux clairs qui peuvent aussi être adaptés selon les standards des différents pays.

Maintiennent les Dix conditions dans leur ordre original de même que les sujets touchés dans chaque condition. Le langage utilisé permettra leur mise à jour éventuelle lors de la publication de nouvelles données probantes. Chaque condition est bien expliquée et contient une orientation claire quant à son implantation.

Reconnaissent la contribution de chaque condition dans l’amélioration du soutien à l’allaitement et soulignent le besoin d’implanter les Dix conditions comme un tout pour obtenir un meilleur impact sur les pratiques lies à l’allaitement.

Fournissent des directives claires pour l’implantation sécuritaires des pratiques et pour le monitoring de celles-ci. Rappellent aux professionnels de la santé l’importance des soins attentifs individualisés.

Décrivent l’importance des pratiques favorables aux mères (Mother-Friendly) et leur impact sur l’allaitement. Mettent l’accent sur l’importance pour les professionnels de la santé de bien connaître ces pratiques et leur responsabilité d’en informer les mères. Réfèrent aux autres lignes directrices en vigueur à l’OMS pour plus de détails concernant ces pratiques.

Soulignent l’importance de l’allaitement et/ou du lait maternel pour tous les bébés soignés dans un établissement, en incluant des directives, des indicateurs et des standards pour le soutien aux bébés prématurés.

Traduction libre par Louise Dumas, Comité canadien pour l’allaitement; texte original en anglais “2018 Baby-Friendly Hospital Initiative

(BFHI) Revised Implementation Guidance” du 11 avril 2018 en plus de directives, d’indicateurs et de standards qui ont toujours fait partie de l’initiative pour les nouveau-nés à terme.

Définissent un mandat clair quant à l’intégration des évidences et des pratiques sous-jacentes aux Dix conditions dans la formation initiale des professionnels de la santé, tout en poursuivant pour le moment l’éducation continue et ce, jusqu’à ce que plusieurs nouveaux gradués ainsi formés soient entrés en milieu clinique au cours des années.

Expliquent les responsabilités des établissements de santé et des professionnels de la santé dans l’implantation du Code international maintenant partie intégrante de la condition 1, décrivant ainsi les bases pour l’adoption du Code international dans tous les aspects des soins aux patients. Soulignent l’importance de la surveillance continue des pratiques et proposent des systèmes pour en assurer la pérennité.

Fournissent des indicateurs clairement définis et faciles à évaluer qui permettent les comparaisons entre les pays. Conservent le niveau de passage à 80% pour tous les indicateurs.

Admettent l’importance de la reconnaissance publique telle la certification, comme élément-clé de changement. Soulignent l’importance de d’évaluation externe comme principe de base pour améliorer la qualité des interventions. Reconnaissent la valeur transformative du processus menant à la certification Ami des bébés sur tout l’environnement lié à la nutrition infantile, entre autres des soins davantage centrés sur le patient, des soignants démontrant des attitudes et des habiletés bonifiées en nutrition infantile, un recours moins fréquent aux substituts du lait maternel et un nombre important de pouponnières fermées. Stipulent que la qualité des soins en regard de l’allaitement évolue grandement quand les maternités sont certifiées Ami des bébés. Offrent des alternatives solides pour améliorer la qualité des soins autrement que par la certification dans les pays où cette option n’est pas envisageable.

Renforcent le rôle des établissements de santé dans l’identification de ressources communautaires appropriées, culturellement et socialement acceptables pour les familles en vue d’un soutien conséquent en allaitement. Rappellent à ces établissements qu’ils ont la responsabilité de s’engager dans leur communauté pour améliorer l’offre de ressources appropriées.

Ce que vous pouvez faire

Étant donné que ce document répond maintenant aux préoccupations que nous avions exprimées suite à la publication d’octobre 2017, nous demandons à toutes les personnes oeuvrant auprès des familles au niveau de la nutrition des nouveau-nés et des jeunes enfants, de se rallier autour de ces Lignes directrices, d’en soutenir les objectifs et de travailler pour l’implanter dans tous les pays de la façon la plus efficace possible.

Prochaines étapes Nous travaillons à nous assurer que la résolution qui sera déposée à l’AMS en mai prochain demandera au Directeur général de l’OMS de travailler en collaboration avec l’UNICEF au développement d’outils pour la formation, la surveillance et la défense de l’IHAB en vue d’assister les états membres à l’implanter dans leur pays respectif. Nous continuerons à suivre le cheminement de cette résolution, le développement des outils requis en vue de l’implantation des lignes directrices sur l’IHAB.

Merci.

Respectueusement vôtre,

Trish MacEnroe
Coordonnatrice
Baby-Friendly Hospital Initiative Network of Industrialized Nations, Central and Eastern European Nations and
Independent States (BFHI Network)

Elisabeth Sterken
Vice-présidente
International Baby Food Action Network (IBFAN)

Michele Griswold
Présidente
Association internationale des consultantes en lactation (ILCA)

Ann Calandro
Présidente
La Ligue La Leche Internationale (LLLI)
Felicity Savage
Présidente
World Alliance for Breastfeeding Action (WABA)

Des traductions supplémentaires de cette communication sont disponibles en anglais et espagnol.


ILCA Volunteer Spotlight: Wilaiporn Rojjanasrirat

Volunteers are essential to achieving our shared goal: world health transformed through breastfeeding and skilled lactation care.

ILCA’s dedicated volunteers take on important roles, including advocating for breastfeeding on the international stage; vetting educational content for our annual conference; promoting equity, diversity and inclusion; and more. Our volunteers share their time, energy, and significant expertise. We want you to learn more about their meaningful efforts.

Today, we are pleased to highlight Wilaiporn Rojjanasrirat, PhD, RNC, IBCLC, Research Team Leader on the Professional Development Committee. Read below for some insights into her volunteer experience at ILCA.

LM: How did you first get involved with ILCA?

Wilaiporn Rojjanasrirat (WR): I got involved in the Research Committee many years ago through my mentor, Dr. Karen Wambach.

LM: What has surprised you most about working with ILCA?

WR: I’ve learned a lot and have gotten to know many wonderful people from all over the world by serving as a volunteer in working with ILCA.

LM: What do you wish other people knew about the specific work of ILCA and/or the Committee(s) and/or Task Forces(s) on which you serve?

WR: Research Team/Committee members have the opportunity to fulfill professional development and research activities by reviewing and selecting abstracts for oral and poster presentation, contributing to other committee activities, and making recommendations of evidence-based monthly resources for ILCA educational modules.

LM: What would you tell someone who is thinking about volunteering at ILCA?

WR: It’s such a rewarding experience to learn and share knowledge/skills in lactation across multiple disciplines and within the IBCLC® profession.

LM: What do you do when you aren’t volunteering?

WR: I enjoy teaching graduate nursing students and working on my research related to breastfeeding.

Please join us in thanking Wilai for her service to ILCA and the profession!

Discussions with the WHO and UNICEF Regarding the Future of the Global Baby-Friendly Hospital Initiative

Dear Colleagues,

We are writing as a collaboration of five organizations that formed to provide unified feedback to the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) in the wake of proposed changes to the Global Baby-Friendly Hospital Initiative (BFHI).

We want to make sure all stakeholders in our networks are informed about the changes WHO and UNICEF have proposed, the concerns we have expressed, and the modifications to the proposals we have recommended. We are also pleased to share with you that WHO and UNICEF have already made some of our recommended changes.

Background

On October 11 of last year the WHO and UNICEF released their draft revised BFHI Operational Guidance titled “Protection, promotion, and support of breastfeeding in facilities providing maternity and newborn services: The revised Baby-friendly Hospital Initiative 2017.”

This document was open for public comment for two weeks and more than 300 individuals and organizations provided feedback during this brief period. As a result of extensive concerns expressed by many stakeholders about the magnitude of the changes proposed and the extremely short timeframe for review and feedback, the WHO and UNICEF decided to delay publication of the proposed BFHI Operational Guidance until there could be further consultations with our five global breastfeeding organizations. Our organizations formed a collaborative, developed a list of 10 key concerns, and have been working closely together since then to provide consolidated and constructive feedback to the WHO and UNICEF on the proposed changes. We are pleased to report that there has been some progress on addressing our concerns.

Areas of Concern

Our collaboration agrees with WHO and UNICEF that the BFHI should be updated, revitalized and include broad and robust components to more effectively guide safe implementation of practices. While we are not included in all discussions underway, our latest information suggests that some critical issues remain:

  1. The proposal still includes the development of individual national criteria. It now includes global standards and recommends that the national criteria be based on them. While this adopts part of our recommendation (maintaining strong global standards), we still believe this approach will allow for wide variation of practices and inconsistent standards throughout the world, undermining global indicators. Global standards are the foundation of the BFHI and they are essential to monitoring the global effort to improve breastfeeding rates. To achieve global standards of practice, there is a need for standardized, model training courses, many of which already exist, and may need only minor adaptation for the revised BFHI.
  2. The proposal includes support for BFHI designation as a key strategy for maternity care practice improvement, however it continues to be optional. We believe optional designation weakens one of the most effective strategies used to achieve sustainable improvements in the quality of maternity care and breastfeeding rates, as evidenced by research and its success in many countries.
  3. The basis for the proposed changes to the Ten Steps is a 136-page review of the evidence released by the WHO on November 3 of last year – after the public comment period for the draft Operational Guidance closed – in a similarly-named document, “Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services.” While each of the Steps was reviewed individually, the review did not address the efficacy of the BFHI program as a whole, which is commonly a key component of program evaluation. Since the GRADE protocol used to create this document only considers randomized controlled trials (RCTs) as appropriate evidence, a significant body of evidence was not examined. This does not equate to lack of or negative evidence. This led initially to the proposed elimination of Step 9, which has now been reinstated, though it does not yet caution against risks of using bottles and pacifiers. While the WHO process for evaluating the evidence on specific topics may have been rigorous and appropriate for addressing narrowly defined quantifiable questions most appropriate for medically related topics, it was not the most appropriate method for examining the evidence related to the socio-cultural and ethical complexities of the BFHI. This method failed to portray the reality that those working and researching in this field have experienced over the past 30 years. It appears that other types of protocols are utilized by the WHO, such as for the newly released Intrapartum Care for Positive Childbirth Experience, which includes all types of quantitative research, for example observational studies, and is not limited to RCTs.
  4. Recent communication from WHO and UNICEF indicates agreement that the order, number and subject matter of each of the original Ten Steps to Successful Breastfeeding will be retained. There will be some modifications to the language and interpretation of the Steps. Most of the changes are improvements and reflect current evidence. We support this action as it enables the Steps to evolve with the evidence. However, the proposed new language for Step 9 remains a concern.
  5. The proposed changes are likely to soften and disrupt ongoing productive and beneficial BFHI work occurring in all corners of the world.
What We Have Done

Our collaborative has sent numerous letters and documents to the WHO and UNICEF and has had many discussions with representatives of these organizations. We also sent a detailed memorandum to Member States’ Representatives to the Executive Board of the World Health Assembly (WHA) prior to their January meeting in Geneva. Several of our members in attendance at the meeting met face-to-face with WHA representatives, and WHO and UNICEF leaders to express our concerns.

WHO and UNICEF, based on an evaluation of the evidence and information submitted by the collaborative, appear to have made significant changes to the proposed initial draft, including the retention of the order, number, and subject matter of each of the original Ten Steps. However, significant gaps in the alignment of our thinking with WHO and UNICEF remain.

We urge the continued delay of publication of the proposed Operational Guidance to allow time for additional conversation and improvements. The WHO and UNICEF’s original plan was to launch the new guidelines in November 2017. According to a recent communication, a new publication date may be late March 2018.

What You Can Do

If you support a continued, comprehensive global review of these issues focused on what’s best for mothers, babies and families, it is critical to let WHO (nutrition@who.int), UNICEF (nutrition@unicef.org) and your WHA representatives hear your concerns immediately. The Operational Guidance could be included in a WHA resolution at the May 2018 meeting to be brought to the table for agreement by Member States. The 2017 WHA delegates list can be found here and may be helpful in identifying and locating your own delegates.

You may wish to emphasize some or all of the following points and recommendations that we continue to advocate for in our discussions:

  1. Retain global: guidelines, criteria, streamlined monitoring tools, streamlined assessment tools, and scoring systems.
  2. Retain standardized model training courses, which can be used or adapted globally.
  3. Continue accreditation based on external assessment, inclusive of mother interviews, and conducted by knowledgeable individuals, as part of the process.
  4. Welcome the indication by WHO and UNICEF that they will maintain the metrics hospitals must achieve at the current 80% standard.
  5. Welcome the indication by WHO and UNICEF to retain the order, number and subject matter of each of the original Ten Steps.
  6. Welcome that the Code and internal monitoring is proposed to be incorporated into Step 1 on infant feeding policies.
  7. Advocate for revised language for the re-introduced Step 9, to clarify facility responsibility for minimizing the use of bottles, teats and pacifiers.  Include language about risks, and the advisability of using only when medically necessary or parents are appropriately educated.
  8. Continue safe and respectful birth practices as a component of the BFHI.
  9. Use empowering language throughout the Operational Guidance document.
  10. Keep the BFHI about healthy term infants. Adopt a separate set of standards pertaining to breastfeeding support for preterm and sick infants, such as the NEO BFHI Baby-Friendly Hospital Initiative for Neonatal Wards which was initially developed by the Nordic-Quebec Working Group.
  11. Include a discussion of the ethical issues related to doing randomized trials on infant and young child feeding including those specific to breastfeeding.
  12. Incorporate a robust discussion regarding the interrelationship between each of the 10 Steps and how they work together as a comprehensive breastfeeding support program.

We appreciate the opportunity to communicate with WHO and UNICEF on this important matter and look forward to continuing to do so in an open and transparent manner. Together, we can strengthen the foundation that supports breastfeeding around the world.

Thank you for your support.

 

Sincerely,

Trish MacEnroe
Coordinator
Baby-Friendly Hospital Initiative Network of Industrialized Nations, Central and Eastern European Nations and Independent States (BFHI Network)

Elisabeth Sterken
Co-chair IBFAN Global Council
International Baby Food Action Network (IBFAN)

Michele Griswold
President
International Lactation Consultant Association (ILCA)

Ann Calandro
Chair
La Leche League International (LLLI)

Felicity Savage
Chair
World Alliance for Breastfeeding Action

 

Additional translations of this communication are available in French and Spanish.

Editor’s Note: The International Lactation Consultant Association would like to applaud the important advocacy efforts of our representatives, Kathleen Marinelli, Joan Dodgson, and Linda Smith, who have worked within this collaborative.

Discussions avec l’OMS et l’UNICEF au sujet de l’avenir de l’Initiative des Hôpitaux Amis des bébés au niveau international

Chères collègues,

Nous vous écrivons au nom d’un collectif de cinq organisations qui s’est développé en vue de fournir à l’Organisation mondiale de la santé (OMS) et à l’UNICEF une rétroaction unifiée sur les changements proposés à l’Initiative des hôpitaux amis des bébés (IHAB) au niveau international.

Nous voulons nous assurer que les membres de nos organisations respectives soient informés correctement sur les changements que l’OMS et l’UNICEF ont proposés, sur les préoccupations que nous avons exprimées, et sur les modifications aux propositions que nous avons recommandées. Nous sommes aussi heureuses de vous informer que l’OMS et l’UNICEF ont déjà accepté quelques-unes de nos recommandations.

Contexte

Le 11 octobre dernier, l’OMS et l’UNICEF ont mis en ligne une révision proposée des Lignes directrices pour l’Initiative des Hôpitaux Amis des bébés (IHAB), sous le titre anglais “Protection, promotion, and support of breastfeeding in facilities providing maternity and newborn services: The revised Baby-friendly Hospital Initiative 2017”.

Ce document était disponible pour consultation publique pour une période de deux semaines. Malgré cette courte période de consultation, plus de 300 individus et organisations ont envoyé des commentaires. Suite aux nombreuses préoccupations exprimées sur l’ampleur des révisions proposées et le temps extrêmement court pour en prendre connaissance et y réagir, l’OMS et l’UNICEF ont décidé de retarder la publication des Lignes directrices proposées en vue de permettre de plus amples consultations avec nos cinq organisations. Depuis ce temps, nos organisations ont formé un collectif, produit une liste de 10 préoccupations clés et travaillé en étroite collaboration, en vue de fournir à l’OMS et l’UNICEF une rétroaction constructive et unifiée quant aux changements proposés.

Sujets de préoccupations qui persistent

Notre collectif est d’accord avec l’OMS et l’UNICEF que l’IHAB a besoin d’être mise à jour, revitalisée et qu’il faut y inclure des éléments solides et à plus large portée en vue de guider l’implantation sécuritaire des pratiques. Cependant, comme notre collectif n’est pas inclus dans toutes les discussions en cours, nos dernières informations suggèrent que certaines questions préoccupantes ne sont pas réglées :

  1. Les changements proposés recommandent toujours aux états-membres de développer leurs propres standards nationaux, même si des critères internationaux seront maintenant proposés comme base au développement des critères nationaux. Nous avions recommandé de maintenir des critères globaux forts, ce qui est fait. Par contre, nous croyons que l’approche de développement de critères nationaux apportera une grande variation dans les pratiques et des standards inégaux à travers le monde, affaiblissant ainsi les critères internationaux. Les standards internationaux sont la fondation même de l’IHAB; ils sont essentiels à la surveillance des efforts globaux visant l’amélioration des taux d’allaitement. Pour atteindre des standards internationaux, il faut aussi un modèle d’éducation continue standardisé; plusieurs de ces cours de formation continue existent et peuvent nécessiter seulement des adaptations mineures.
  2. Les changements proposés soutiennent que la certification IHAB est une stratégie clé pour l’amélioration des pratiques mais qu’elle demeure optionnelle. Nous croyons que ceci affaiblira l’une des stratégies reconnues les plus efficaces pour améliorer de façon durable la qualité des soins périnatals et augmenter les taux d’allaitement, tel que démontré par les recherches et l’expérience terrain dans plusieurs pays.
  3. Une communication récente de l’OMS et de l’UNICEF indique que la structure des Dix conditions pour le succès de l’allaitement, leur ordre original ainsi que l’objet de chacune d’elles seront retenus. Plusieurs changements de langage et d’interprétation sont à prévoir en vue de refléter les plus récentes données probantes. Nous soutenons cette décision qui permettra l’évolution des conditions selon les évidences scientifiques. Cependant, le libellé proposé pour la condition 9 pose encore un problème.
  4. Les changements proposés aux Dix conditions sont basés sur une revue des données probantes de 136 pages publiée par l’OMS le 3 novembre 2017-après la période de consultation publique sur les Lignes directrices- dans un document portant un nom similaire “Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services”. Dans cette revue des évidences scientifiques, les Dix conditions ont été étudiées individuellement mais l’efficacité de l’IHAB comme un tout n’a pas été considérée; pourtant, ceci fait généralement partie de l’évaluation d’un programme. Le protocole  GRADE utilisé pour cette recherche de données probantes ne considère que les études randomisées contrôlées (RCTs) comme évidence scientifique acceptable. En conséquence, un large éventail de la littérature scientifique n’a pas examiné, ce qui n’équivaut pas à un manque d’évidence ni à des données scientifiques négatives. C’est entre autres ce processus qui a conduit à la proposition initiale d’éliminer la Condition 9 qui a, depuis, été réinscrite dans les Dix conditions; cependant actuellement, la condition 9 n’inclut pas de mention des risques associés à l’utilisation des biberons et des sucettes. Même si ce protocole est  rigoureux et approprié pour l’étude d’une question quantifiable définie précisément, par exemple une question médicale pointue, ce n’est pas la méthode la plus appropriée pour évaluer les évidences scientifiques liées aux aspects socio-culturels et éthiques complexes de l’IHAB. Le protocole GRADE utilisé pour étudier les données probantes liées à l’IHAB ne dépeint pas la réalité de ceux et celles qui travaillent et font de la recherche dans ce domaine depuis plus de trente ans. Il semble que l’OMS utilise d’ailleurs d’autres protocoles de revue de la littérature qui incluent aussi d’autres types de recherches quantitatives en plus des RCTs,  par exemple des études observationnelles, comme c’est le cas pour le document récemment publié Intrapartum Care for Positive Childbirth Experience.
  5. Les changements proposés vont fort probablement miner le travail productif et bénéfique effectué actuellement en regard de l’IHAB dans tous les coins du monde.
Ce que nous avons fait

Notre collectif a eu de nombreuses discussions avec les représentants de l’OMS et de l’UNICEF et leur a fait parvenir plusieurs lettres et documents. Nous avons aussi envoyé un mémorandum aux membres du Comité exécutif de l’Assemblée mondiale de la santé avant leur rencontre à Genève en janvier dernier. Des membres de notre collectif, présents sur place, ont aussi rencontré individuellement plusieurs délégués de même que les responsables de l’IHAB de l’OMS et de l’UNICEF, en vue de leur expliquer de vive voix nos préoccupations.

Suite à l’évaluation des données probantes et des informations que notre collectif leur a soumises, l’OMS et l’UNICEF semblent avoir apporté de nombreux changements au canevas proposé initialement, incluant la structure, l’ordre et l’objet des Dix conditions. Cependant, on constate qu’encore actuellement, la vision de l’OMS-UNICEF et la nôtre ne concordent pas entièrement.

Nous demandons de retarder la publication des Lignes directrices actuellement proposées en vue de poursuivre le travail pour bonifier ce document. L’OMS et UNICEF planifiaient de publier ce document en novembre 2017. Selon la lettre que nous avons reçue, la publication pourrait avoir lieu en mars 2018.

Ce que vous pouvez faire

Si vous êtes d’accord qu’une révision globale, continue et inclusive de ces préoccupations, doit être poursuivie, centrée sur ce qu’il y a de meilleur pour les mères et les bébés, il est important que l’OMS (nutrition@who.int), l’UNICEF (nutrition@unicef.org) et vos délégués nationaux à l’Assemblée mondiale de la santé (AMS) vous entendent immédiatement. Les nouvelles Lignes directrices pourraient faire l’objet d’une résolution demandant le vote des délégués à l’AMS en mai 2018. La liste des délégués des états-membres de 2017 se trouve sur ce site web afin de vous permettre d’identifier et de rejoindre vos propres délégués.

Vous désirerez peut-être alors discuter avec eux de l’un ou de tous les points et recommandations sur lesquels nous continuons à insister lors de nos discussions, à savoir:

  1. Garder au niveau international : lignes directrices, critères, outils simplifiés pour le monitoring, méthodes et outils d’évaluation et de compilation.
  2. Conserver un modèle standardisé de formation continue qui peut être utilisé tel quel ou adapté au niveau international.
  3. Considérer l’évaluation externe comme partie prenante du processus de certification, incluant les entrevues de mères menées par des individus ayant les compétences pour le faire.
  4. Accueillir favorablement l’intention de l’OMS/UNICEF de conserver les pourcentages de passage à 80% pour les établissements de santé.
  5. Accueillir favorablement l’indication que l’OMS/UNICEF gardera la structure et l’ordre des Dix conditions, de même que l’objet de chacune d’entre elles.
  6. Accueillir favorablement le fait que le Code et la surveillance (monitoring) seront intégrés dans la condition 1 sur les politiques d’alimentation de l’enfant.
  7. Militer pour un langage approprié pour la condition 9 qui a été réinscrite aux Dix conditions. Clarifier ainsi le rôle des établissements de santé pour minimiser l’utilisation de biberons, de suces et de sucettes. Utiliser un langage spécifiant les risques liés à ces produits et l’opportunité de leur utilisation sur indication médicale  seulement ou après que les parents aient été informés de façon appropriée.
  8. Conserver comme critères évaluables dans l’IHAB, les pratiques respectueuses et sécuritaires au moment de la naissance.
  9. Utiliser dans tout le document des Lignes directrices un langage visant l’empowerment des personnes.
  10. Inclure uniquement les bébés à terme et en santé dans l’IHAB. Adopter des standards différents et à part de l’évaluation régulière, pour le soutien à l’allaitement des bébés prématurés et/ou malades, par exemple le NEO BFHI, un guide sur l’Initiative des hôpitaux amis des bébés appliquée aux unités de soins intensifs néonataux, développé à l’origine par le Nordic-Quebec Working Group.
  11. Inclure dans les Lignes directrices une solide discussion sur les aspects éthiques liés aux études randomisées en ce qui concerne la nutrition des nourrissons et des jeunes enfants, incluant spécifiquement celles en regard de l’allaitement.
  12. Insérer dans les Lignes directrices une explication détaillée des interrelations entre les Dix conditions et comment l’IHAB fonctionne comme un programme intégré de soins et services.

Nous saluons l’opportunité de travailler avec l’OMS et l’UNICEF à cet important changement et espérons de continuer ainsi dans la transparence et l’ouverture. Ensemble, nous pouvons solidifier les fondations qui soutiennent l’allaitement internationalement.

Merci de votre soutien.

 

Acceptez nos salutations respectueuses,

Trish MacEnroe, coordonnatrice, Baby-Friendly Hospital Initiative Network of Industrialized Nations, Central and Eastern European Nations and Independent States (BFHI Network)

Elizabeth Sterken, vice-présidente, International Baby Food Action Network (IBFAN)

Michele Griswold, présidente, Association internationale des consultantes en lactation (ILCA)

Ann Calandro, présidente, La Ligue La Leche International (LLLI)

Felicity Savage, présidente, World Alliance for Breastfeeding Action (WABA)

 

Traduction libre par Louise Dumas, Comité canadien pour l’allaitement; texte original en anglais “Discussions with the WHO and UNICEF Regarding the Future of the Global Baby-Friendly Hospital Initiative”.

Des traductions supplémentaires de cette communication sont disponibles en anglais et espagnol.

Note de la rédaction: L’International Lactation Consultant Association aimerait féliciter les représentants de nos représentants, Kathleen Marinelli, Joan Dodgson et Linda Smith, qui ont travaillé dans le cadre de ce projet de collaboration.

Negociaciones con la OMS y con UNICEF sobre el futuro de la IHAN (Hospital Amigo de los Niños y las Niñas) a Nivel Internacional

Estimados colegas:

Os escribimos en nombre de la alianza formada por nuestras 5 organizaciones al objeto de ofrecer, a la Organización Mundial de la Salud (OMS) y el Fondo de las Naciones Unidas para la Infancia (UNICEF), una respuesta unificada ante las propuestas de cambios a nivel Global para la IHAN (Iniciativa Hospital amigo de los niños y las niñas o (en España) Iniciativa para la Humanización de la Asistencia al Nacimiento y la Lactancia).

Es nuestro deseo hacer llegar, dentro de nuestras redes, a todas las partes interesadas, la información de los cambios que OMS y UNICEF han propuesto, así cómo las preocupaciones que nuestra alianza les ha expresado junto a las modificaciones que hemos propuesto.

Antecedentes

El 11 de octubre del pasado año, OMS y UNICF hicieron público un documento preliminar de la Guía Operativa IHAN titulado: “Protection, promotion, and support of breastfeeding in facilities providing maternity and newborn services: The revised Baby-friendly Hospital Initiative 2017.” (sólo publicado en inglés)

Este documento estuvo abierto a comentario público durante 2 semanas y, en tan corto espacio de tiempo, obtuvo comentarios de más de 300 individuos y organizaciones. Como resultado de la importante inquietud, expresada por muchas de las partes implicadas, sobre la magnitud de los cambios propuestos y sobre la extrema brevedad del tiempo concedido para hacer revisiones y propuestas, OMS y UNICEF decidieron retrasar la publicación de la Revisión de la Guía Operacional para la IHAN hasta que pudieran tener lugar consultas de mayor profundidad con nuestras 5 organizaciones (de ámbito mundial). Nuestras organizaciones formaron una alianza y hemos estado trabajando unidas desde entonces, con el propósito de ofrecer una respuesta conjunta, consolidada y constructiva sobre los cambios propuestos, a la OMS y el UNICEF. Nos satisface poder comunicar en este punto que, de alguna manera, la respuesta a nuestras preocupaciones está realizando progresos.

Motivos de preocupación

Estamos de acuerdo con que la IHAN debe ser actualizada, revitalizada e incluir componentes sólidos que aseguren de forma más efectiva su implementación. Aunque no estamos incluidas en todas las discusiones que están teniendo lugar, nuestras últimas informaciones sugieren la persistencia de algunos puntos críticos.

  1. La propuesta aún incluye el desarrollo de criterios nacionales individuales. Aunque ahora incluye los Criterios Globales y recomienda que los criterios nacionales se basen en ellos. A pesar de que parte de nuestras recomendaciones son adoptadas (mantener unos Criterios Globales Fuertes), creemos no obstante que este enfoque abre la posibilidad a una amplia variabilidad de prácticas y a la inconsistencia de estándares a nivel mundial, y socava los indicadores globales. Los Criterios Globales son la base fundacional de la IHAN y son esenciales en la monitorización de los esfuerzos que a nivel global se realizan para mejorar las tasas de lactancia materna. Para conseguir estándares de práctica globales, son necesarios cursos modelo de formación estandarizados, muchos de los cuales ya existen y necesitarían tan sólo pequeñas adaptaciones a la IHAN revisada.
  2. La propuesta incluye la certificación IHAN de las instituciones como una estrategia clave en la mejora de las prácticas de cuidado en las maternidades, pero continua considerándola como opcional. Creemos que la consideración de opcional debilitaría una de las estrategias más efectivas para la obtención de mejoras sostenibles en la calidad de los cuidados en las Maternidades y en las Tasas de Lactancia, avalada por la evidencia científica y la experiencia de muchos países.
  3. Comunicaciones recientes desde OMS y UNICEF indican un acuerdo sobre el mantenimiento del orden, el número y el contenido esencial de cada uno de los 10 Pasos hacia una lactancia natural, originales. Habrá algunas modificaciones de definición y de interpretación de los Pasos. La mayoría de estos cambios son mejoras y reflejan la evidencia científica actual. Sin embargo seguimos considerando preocupante la nueva definición del Paso 9.
  4. La base para los cambios propuestos para los 10 Pasos, es una revisión de 136 páginas sobre la evidencia, publicada por la OMS el 3 de noviembre del año pasado- después del periodo abierto a comentario público para la guía operativa- en un documento denominado de forma muy similar: “Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services.” A pesar de que cada uno de los Pasos fue revisado individualmente, la revisión no abordó la eficacia del programa IHAN como un todo, lo que es un componente habitualmente clave en la evaluación de programas. Dado que en el protocolo GRADE, utilizado para la elaboración de este documento, la única evidencia considerada apropiada fue la derivada de ensayos clínicos, un conjunto significativo de evidencia quedó por examinar. Pero ello no significa que no haya evidencia o que la evidencia existente sea negativa. Los resultados de este análisis llevaron a la propuesta inicial de eliminación del Paso 9 que ha sido ahora reinstaurado, aunque sin que avise contra los riesgos de utilizar biberones y chupetes. A pesar de que el proceso aplicado por la OMS puede haber sido riguroso y apropiado para abordar la calidad de la evidencia sobre otros temas concretos, medibles cuantitativamente con preguntas de definición precisa, como ocurre especialmente en determinadas cuestiones del ámbito médico, este proceso no es el método más adecuado para examinar la evidencia relacionada con las complejidades socio-culturales y éticas que rodean a la IHAN. Este método ha fracasado en el retrato de la realidad que aquellos que llevan trabajando e investigando en este campo han experimentado en los 30 años. Al parecer en casos similares, otro tipo de protocolos son utilizados por la OMS, como el usado en el documento publicado recientemente: Intrapartum Care for Positive Childbirth Experience que incluye cualquier tipo de diseño de investigación cuantitativa incluyendo estudios observacionales, y no se limita al ámbito de los ensayos clínicos.
  5. Es muy probable que los cambios propuestos debiliten y perturben el trabajo productivo y beneficios de la IHAN que en la actualidad tiene lugar en todos los rincones del mundo.
Lo que hemos hecho

Nuestra alianza ha enviado numerosas cartas y documentos a la OMS y a UNICEF y hemos mantenido múltiples debates con representantes de estas organizaciones. También enviamos un detallado memorando a los Representantes de los Estados Miembros en el Comité Ejecutivo de la Asociación Mundial de la Salud (AMS) antes de su reunión de enero en Ginebra. Durante su asistencia a la reunión, varios de nuestros miembros mantuvieron encuentros vis-a-vis con representantes de la AMS y con los líderes de OMS y UNICEF y les comunicaron nuestras preocupaciones.

Basados en la evaluación de la evidencia y en la información remitida por nuestra alianza, OMS y UNICEF parecen haber realizado cambios sustanciales en el borrador-propuesta inicial, incluyendo el mantenimiento del orden, el número y el contenido de cada uno de los 10 Pasos originales. Sin embargo aún persisten numerosas brechas en el alineamiento de nuestros planteamientos con los de OMS y UNICEF.

Urgimos a mantener el retraso de la publicación de la propuesta de Guía Operacional que conceda tiempo para conversaciones y mejoras adicionales. El plan original de OMS y UNICEF era la publicación de la Nueva Guía en noviembre de 2017. Según una comunicación reciente, hay una nueva fecha probable de publicación: finales de marzo 2018.

Qué podéis hacer

Si apoyáis continuar con una revisión exhaustiva y global de este tema, dirigida a la búsqueda de lo mejor para madres y bebés, es crítico que OMS, UNICEF y vuestros representantes en la Asamblea Mundial de la Salud oigan vuestras preocupaciones de forma inmediata. La Guía Operacional podría ser incluida en una resolución de la Asamblea Mundial de la Salud que será presentada para su aprobación por los estados miembros en la reunión de mayo de 2018. La lista de delegados de 2017 puede verse aquí y podría ser útil para identificar y localizar a vuestros propios delegados.

Podríais desear enfatizar algunos o todos de los siguientes puntos y recomendaciones que continuamos promoviendo en nuestras negociaciones con OMS y UNICEF:

  1. Conservar globales las guías, los criterios, las herramientas simplificadas de monitorización y evaluación y los sistemas de puntuación.
  2. Mantener el modelo de curso de formación estandarizado que puede ser usado o adaptado a nivel mundial.
  3. Continuar con las acreditaciones, como parte del proceso, basadas en evaluaciones externas que incluyan entrevistas con madres y sean realizadas por expertos.
  4. Dar la bienvenida a la indicación de OMS y UNICEF de que mantendrán los niveles de cumplimiento para los hospitales en un 80% del estándar.
  5. Agradecer la indicación de OMS y UNICEF de mantener el orden, el número y el sentido original de los 10 Pasos.
  6. Celebrar el hecho de que el Código y el sistema de monitorización interna sean incorporados en el Paso 1 sobre políticas de alimentación infantil.
  7. Recomendar la revisión del texto utilizado en el recuperado Paso 9, para clarificar la responsabilidad de la institución de minimizar el uso de biberones, tetinas y chupetes. Incluir texto sobre riesgos, y la necesidad de que los padres reciban información sobre las implicaciones que conlleva el uso de biberones, tetinas y chupetes.
  8. Continuar manteniendo las prácticas de seguridad y respeto en el parto como un componente de la IHAN.
  9. Incorporar lenguaje motivador a lo largo del documento de la Guía Operacional.
  10. Mantener como sujetos objeto de la IHAN a los recién nacidos sanos. Adoptar un conjunto diferente de estándares en relación al apoyo de la lactancia en los recién nacidos enfermos o prematuros, como la NEO-IHAN desarrollada por la alianza de países nórdicos y Canadá.
  11. Incluir un apartado que trate de los aspectos éticos relacionados con la realización de ensayos clínicos aleatorios en la investigación en lactancia materna.
  12. Incorporar una discusión sólida sobre cómo Los 10 Pasos se interrelacionan en un todo global y constituyen un programa integral de apoyo a la lactancia materna.

Apreciamos sinceramente la oportunidad de comunicación con la OMS y UNICEF en este tema importante y esperamos continuar haciéndolo de manera fluida. Juntos, podemos fortalecer los cimientos que apoyan la lactancia en todo el mundo.

Muchas gracias por vuestro apoyo.

 

Sinceramente

Trish MacEnroe, coordinadora, Red Global Iniciativa Baby-Friendly para los países industrializados y CEEIS (BFHI Network)

Elizabeth Sterken, vicepresidenta, International Baby Food Action Network (IBFAN)

Michele Griswold, presidenta, Asociación Internacional de consultoras de lactancia (ILCA)

Ann Calandro, presidenta, La Liga de La Leche Internacional (LLLI)

Felicity Savage, presidenta, World Alliance for Breastfeeding Action (WABA)

 

Traducción autorizada del texto original en inglés : “Discussions with the WHO and UNICEF Regarding the Future of the Global Baby-Friendly Hospital Initiative”. Traducción realizada por Mª Teresa Hernández Aguilar, Coordinadora Nacional IHAN- España (Iniciativa para la Humanización de la Asistencia al Nacimiento y la Lactancia).

Las traducciones adicionales de esta comunicación están disponibles en inglésfrancés.

Nota del editor: La Asociación Internacional de Consultores de Lactancia quisiera aplaudir los importantes esfuerzos de defensa y promoción de nuestros representantes, Kathleen Marinelli, Joan Dodgson y Linda Smith, quienes han trabajado en esta colaboración.

Discussioni con l’OMS e l’UNICEF riguardo al futuro dell’Iniziativa mondiale Ospedale Amico dei Bambini

Cari Colleghi,

vi scriviamo a nome di cinque Organizzazioni (BFHI Network, IBFAN, ILCA, LLLI, WABA), che si sono riunite per fornire un feedback all’Organizzazione Mondiale della Sanità (OMS) e al Fondo delle Nazioni Unite per l’Infanzia (UNICEF) in seguito alle modifiche da loro proposte all’Iniziativa mondiale Ospedale Amico dei Bambini (Baby-Friendly Hospital Initiative – BFHI).

Vogliamo assicurarci che tutte le parti interessate delle nostre reti siano informate sui cambiamenti che OMS e UNICEF hanno proposto, sulle preoccupazioni che abbiamo espresso e sulle modifiche che abbiamo formulato alle loro proposte. Siamo contente di riferirvi che OMS e UNICEF hanno già accolto alcune delle nostre proposte di modifica.

Cronostoria

L’11 ottobre scorso OMS e UNICEF hanno pubblicato la bozza della Guida operativa BFHI riveduta dal titolo “Protection, promotion, and support of breastfeeding in facilities providing maternity and newborn services: The revised Baby-friendly Hospital Initiative 2017.” (“Protezione, promozione e sostegno dell’allattamento in strutture che offrono servizi di maternità e per neonati: l’Iniziativa Ospedale Amico dei Bambini rivista nel 2017”).

Questo documento è stato messo a disposizione dei commenti del pubblico per due settimane e più di 300 persone e organizzazioni hanno fornito un feedback durante questo breve periodo. In base alle preoccupazioni generali espresse da più parti sull’entità delle modifiche proposte e sui tempi estremamente brevi concessi per leggere la bozza e fornire un feedback, OMS e UNICEF hanno deciso di rinviare la pubblicazione della bozza della Guida operativa BFHI per permettere ulteriori consultazioni con le nostre cinque organizzazioni che si occupano di allattamento. Da allora, le nostre organizzazioni hanno formato un gruppo di lavoro, sviluppato un elenco di 10 aree di criticità, e lavorato a stretto contatto per fornire un feedback consolidato e costruttivo a OMS e UNICEF sulle modifiche proposte. Siamo felici di comunicarvi che sono stati fatti dei progressi nell’accogliere le nostre preoccupazioni.

Aree di criticità che persistono

Il nostro gruppo di lavoro è d’accordo con OMS e UNICEF sul fatto che la BFHI andrebbe aggiornata e rivitalizzata e che dovrebbe includere elementi ad ampio raggio e di comprovata evidenza scientifica per guidare in modo più efficace l’applicazione sicura delle pratiche. Anche se il nostro gruppo non è stato incluso in tutte le discussioni in corso, le ultime informazioni suggeriscono che alcune questioni preoccupanti perdurano:

 

  1. La bozza della Guida operativa del 2017 parla ancora dello sviluppo di criteri nazionali. Include ancora gli standard globali, ma solo come base per gli standard nazionali. Anche se una parte della nostra raccomandazione (mantenere standard globali forti) è stata accolta, continuiamo a ritenere che questo approccio porti ad una variabilità troppo ampia di pratiche e a standard non coerenti a livello mondiale, minando di fatto il senso degli indicatori globali. Gli standard globali sono alla base della BFHI e sono essenziali per monitorare lo sforzo mondiale per migliorare i tassi di allattamento. Per raggiungere gli standard internazionali di buone pratiche, è essenziale avere dei modelli di corsi di formazione standardizzati, che già esistono in gran parte, e che potrebbero richiedere soltanto piccoli adattamenti per questa revisione della BFHI.
  2. La bozza sostiene il riconoscimento di “Ospedale Amico” come strategia-chiave per migliorare l’assistenza materno-infantile, ma il riconoscimento continua ad essere una componente facoltativa. Riteniamo che un riconoscimento “optional” indebolisca una delle strategie più efficaci utilizzate per ottenere miglioramenti sostenibili nella qualità dell’assistenza materno-infantile e nei tassi di allattamento, come evidenziato dalla ricerca e dalla buona riuscita dell’iniziativa in molti paesi.
  3. Una comunicazione recente di OMS e UNICEF indica un accordo sul fatto che la struttura, la numerazione e i temi di ognuno dei Dieci Passi originali verranno mantenuti. Verranno apportate modifiche alla descrizione e all’interpretazione di diversi Passi. La maggior parte delle modifiche rappresenta un miglioramento e riflette le prove di efficacia attuali. Noi sosteniamo questa azione che permette ai Dieci Passi di evolvere con la ricerca. Tuttavia, la definizione proposta per il Passo 9 rimane una criticità.
  4. Le modifiche proposte ai Dieci Passi si basano su una revisione della letteratura di 136 pagine pubblicata dall’OMS il 3 novembre u.s. – dopo il periodo per commenti pubblici – dal titolo molto simile: “Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services.” (“Proteggere, promuovere e sostenere l’allattamento in strutture che offrono servizi di maternità e per neonati.”). Mentre sono stati presi in considerazione ognuno dei Passi in maniera singola, la revisione non ha affrontato l’efficacia del programma BFHI nel suo complesso, che solitamente rappresenta una componente chiave della valutazione complessiva di un programma. Il protocollo GRADE utilizzato per creare questo documento, ha preso in considerazione i trials randomizzati controllati (Randomized Controlled Trials – RCTs) come prova utile. Un corpus significativo di ricerche non è stato esaminato, il che non significa una mancanza di prove oppure prove negative. Questo approccio ha portato alla proposta iniziale di eliminare il Passo 9, che attualmente risulta re-inserito, sebbene non metta ancora in guardia sui rischi associati all’uso di biberon e tettarelle. Mentre il processo dell’OMS per la valutazione delle prove di efficacia per argomenti specifici può essere rigoroso ed appropriato per indagare su questioni ben definite e quantificabili come quelle che si incontrano tipicamente in ambiti medici, non è il metodo più adatto per esaminare le prove di efficacia che riguardano le complessità socio-culturali ed etiche della BFHI. Questo metodo non è riuscito a rappresentare la realtà delle persone che lavorano nell’ambito della BFHI e che in questo ambito hanno fatto ricerca negli ultimi 30 anni. Sembra che ci siano altri tipi di protocolli utilizzati dall’OMS, come quello per il documento di recente pubblicazione “Intrapartum Care for Positive Childbirth Experience” (“Assistenza al travaglio/parto per un’esperienza positiva della nascita”), che esamina tutti i tipi di ricerca quantitativa, come per esempio gli studi osservazionali, e non si limita agli RCTs.
  5. Le modifiche proposte rischiano di attenuare e interrompere gli sforzi efficaci e produttivi portati avanti per la BFHI in tutti gli angoli del mondo.
Cosa abbiamo fatto

Il nostro gruppo ha inviato numerose lettere e documenti a OMS e UNICEF e ha avuto molte discussioni con i rappresentanti di queste Organizzazioni. Abbiamo anche inviato un dettagliato memorandum ai rappresentanti degli Stati Membri del Comitato Esecutivo dell’Assemblea Mondiale della Sanità (World Health Assembly – WHA) prima della loro riunione di gennaio a Ginevra. Alcuni nostri rappresentanti presenti all’incontro si sono incontrati faccia a faccia con i rappresentanti della WHA, i leader dell’OMS e dell’UNICEF per esprimere le nostre preoccupazioni.

Sembra che OMS e UNICEF, basandosi su una valutazione delle prove e delle informazioni fornite dal gruppo, abbiano apportato modifiche sostanziali alla bozza iniziale proposta, compreso l’aver mantenuto la struttura, la numerazione e i temi di ognuno dei Dieci Passi originali. Tuttavia, permangono notevoli distanze fra il nostro pensiero e quello di OMS e UNICEF.

Continuiamo a premere per posticipare la pubblicazione della Guida operativa proposta, al fine di concedere ulteriore tempo, scambi di idee e miglioramenti. Il piano originale di OMS e UNICEF prevedeva di lanciare le nuove linee guida a novembre 2017. Secondo una comunicazione recente, una nuova data di pubblicazione potrebbe essere a fine marzo 2018.

Cosa potete fare

Se sostenete una continua e comprensiva revisione globale di questi temi incentrata su ciò che è meglio per madri e bambini, è fondamentale far sentire le vostre preoccupazioni in tempi brevi all’OMS (nutrition@who.int), all’UNICEF (nutrition@unicef.org) ed ai vostri rappresentanti WHA. A maggio prossimo, alla riunione della WHA, la bozza della Guida Operativa potrebbe essere messa in agenda come uno degli argomenti di discussione degli Stati Membri. L’elenco dei delegati WHA del 2017 si trova qui e può essere utile per identificare e ritrovare i propri delegati.

Potreste voler sottolineare alcuni o tutti i seguenti punti e raccomandazioni che continuiamo a promuovere nelle nostre discussioni:

  1. Mantenere i materiali globali: le linee guida, i criteri globali, strumenti snelli di monitoraggio, di valutazione e di assegnazione di punteggio.
  2. Mantenere modelli di corsi di formazione standardizzati, che si possono utilizzare o adattare a livello globale.
  3. Mantenere il riconoscimento basato su valutazioni esterne, comprensive di interviste alle madri, condotte da persone appositamente formate, come parte del processo.
  4. Accogliere l’indicazione espressa da parte di OMS e di UNICEF che verranno mantenuti i livelli minimi che gli ospedali devono raggiungere all’attuale standard dell’80%.
  5. Accogliere l’indicazione espressa da parte di OMS e UNICEF che verranno mantenuti la struttura, la numerazione e i temi di ognuno dei Dieci Passi originali.
  6. Accogliere l’indicazione espressa che il Codice Internazionale ed il monitoraggio facciano parte integrante del Passo 1 sulle politiche dell’alimentazione dei neonati e dei bambini.
  7. Spingere affinché il Passo 9, re-introdotto, chiarisca la responsabilità della struttura nell’assicurare un utilizzo minimo di biberon, tettarelle e ciucci. Inserire indicazioni sui rischi e sull’opportunità di utilizzarli solo su indicazione medica oppure dopo un consenso informato dei genitori.
  8. Mantenere le pratiche di travaglio/parto sicure e rispettose come componente della BFHI.
  9. Privilegiare un linguaggio di empowerment, che rende le donne e le famiglie protagoniste, in tutta la Guida Operativa.
  10. Mantenere il focus della BFHI sui neonati sani. Adottare una serie distinta di standard relativi al supporto dell’allattamento per neonati pretermine e malati, come nella Néo BFHI, l’iniziativa per i reparti di patologia neonatale e terapia intensiva sviluppata inizialmente dal Gruppo di Lavoro Nordico e del Québec.
  11. Includere una discussione sulle questioni etiche relative alla svolgimento di studi randomizzati su temi che riguardano l’alimentazione dei neonati e dei bambini, compresi quelli specifici sull’allattamento.
  12. Includere una discussione approfondita sull’interrelazione tra ciascuno dei 10 Passi e su come essi agiscono in sinergia per formare un intervento completo di sostegno all’allattamento.

Apprezziamo l’opportunità dello scambio di idee con OMS e con UNICEF in questo passaggio importante e ci auguriamo di proseguire questo lavoro in modo aperto e trasparente. Insieme, possiamo rafforzare le fondamenta che supportano l’allattamento in tutto il mondo.

 

Grazie del vostro sostegno,

Trish MacEnroe
Coordinator
Baby-Friendly Hospital Initiative Network of Industrialized Nations, Central and Eastern European Nations and Independent States (BFHI Network)

Elisabeth Sterken
Co-chair IBFAN Global Council
International Baby Food Action Network (IBFAN)

Michele Griswold
President
International Lactation Consultant Association (ILCA)

Ann Calandro
Chair
La Leche League International (LLLI)

Felicity Savage
Chairperson
World Alliance for Breastfeeding Action (WABA)

Traduzione autorizzata del testo originale in inglese: “Discussions with the WHO and UNICEF Regarding the Future of the Global Baby-Friendly Hospital Initiative”. Traduzione a cura di Elise Chapin.

Ulteriori traduzioni di questa comunicazione sono disponibili in inglese, francese e spagnolo.

Negociações com a OMS e com o UNICEF sobre o futuro da Iniciativa Hospital Amigo da Criança (IHAC) em âmbito internacional

Caros colegas:

Estamos escrevendo em nome da aliança formada por nossas 5 organizações a fim de oferecer à Organização Mundial da Saúde (OMS) e ao Fundo das Nações Unidas para a Infância (UNICEF) uma resposta unificada às mudanças propostas em âmbito global para a Iniciativa Hospital Amigo da Criança (IHAC).

É nosso desejo divulgar, dentro de nossas redes e a todas as partes interessadas, informações sobre as mudanças que a OMS e o UNICEF propuseram, bem como as preocupações que nossa aliança expressou a estes organismos, juntamente com as modificações que propusemos.

Antecedentes

Em 11 de outubro do ano passado, a OMS e o UNICF divulgaram um documento preliminar do Guia Operacional da IHAC, intitulado: “Protection, promotion, and support of breastfeeding in facilities providing maternity and newborn services: The revised Baby-friendly Hospital Initiative 2017” (publicado apenas em inglês).

Este documento esteve aberto a comentários públicos por duas semanas e, em tão curto período de tempo, recebeu comentários de mais de 300 indivíduos e organizações. Em decorrência da significativa preocupação, expressa por muitas das partes envolvidas, com a magnitude das mudanças propostas e o prazo extremamente breve concedido para fazer revisões e propostas, a OMS e o UNICEF decidiram adiar a publicação da Revisão do Guia Operacional da IHAC até que fosse possível realizar consultas mais aprofundadas com nossas cinco organizações (em âmbito mundial). Nossas organizações formaram uma aliança e estamos trabalhando juntos desde então, com o objetivo de oferecer uma resposta conjunta, consolidada e construtiva às mudanças propostas, à OMS e ao UNICEF. Sentimo-nos satisfeitos em poder informar que até este momento, de alguma forma, a resposta às nossas preocupações está em progresso.

Motivos de preocupação existentes

Estamos de acordo com que a IHAC deva ser atualizada, revitalizada e incluir componentes sólidos que garantam sua implementação de forma mais efetiva. Embora não estejamos incluídos em todas as discussões que estão ocorrendo, nossas últimas informações sugerem a persistência de alguns pontos críticos.

 

  1. A proposta ainda inclui o desenvolvimento de critérios nacionais individuais, ainda que agora inclua também os Critérios Globais e recomende que os critérios nacionais sejam baseados neles. Embora uma parte de nossas recomendações haja sido adotada (manter Critérios Globais fortes), acreditamos, no entanto, que essa abordagem abre a possibilidade de uma ampla variedade de práticas e de inconsistência das normas em âmbito mundial, de modo a prejudicar os indicadores globais. Os Critérios Globais são a base fundamental da IHAC e são essenciais no monitoramento dos esforços gerais para melhorar as taxas de aleitamento materno. Para alcançar padrões globais de práticas, são necessários cursos de formação padronizados, muitos dos quais já existem e exigem apenas pequenas adaptações à IHAC revisada.
  2. A proposta inclui a certificação IHAC das instituições como uma estratégia chave para melhorar as práticas de cuidado nas maternidades, mas continua considerando-a como opcional. Acreditamos que considerá-la como opcional enfraquece uma das estratégias mais efetivas para a obtenção de melhorias sustentáveis ​​na qualidade dos cuidados nas maternidades e nas taxas de aleitamento materno, apoiada por evidências científicas e a experiência de muitos países.
  3. Comunicações recentes da OMS e do UNICEF indicam um acordo sobre a manutenção da ordem, do número e do conteúdo essencial de cada um dos 10 Passos para o Sucesso do Aleitamento Materno. Haverá algumas modificações na definição e na interpretação dos Passos. A maioria dessas mudanças são melhorias e refletem a evidência científica atual. No entanto, continuamos considerando preocupante a nova definição do passo 9.
  4. A base para as mudanças propostas para os 10 Passos é uma revisão de 136 páginas sobre evidências, publicada pela OMS em 3 de novembro do ano passado – após o período aberto para comentários públicos do Guia Operacional – em um documento denominado de modo muito similar: “Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services”. Embora cada um dos Passos tenha sido revisado individualmente, a revisão não abordou a eficácia do programa IHAC como um todo, o que é um componente geralmente chave na avaliação de programas. Dado que no protocolo GRADE, utilizado para a preparação desse documento, a única evidência considerada apropriada foi a resultante de ensaios clínicos, um conjunto significativo de evidências não foi examinado. Mas isso não significa que não haja evidências ou que a evidência existente seja negativa. Os resultados desta análise levaram à proposta inicial para a eliminação do Passo 9, que agora foi reintegrado, ainda que não avise sobre os riscos de usar mamadeiras e chupetas. Embora o processo aplicado pela OMS possa ter sido rigoroso e apropriado para abordar a qualidade das evidências em outras questões específicas, mensuráveis ​​quantitativamente com questões de definição precisa, como ocorre especialmente em certas questões do campo médico, esse processo não é o método mais apropriado para examinar as evidências relacionadas às complexidades socioculturais e éticas que cercam a IHAC. Este método falhou em retratar a realidade que aqueles que trabalham e pesquisam neste campo vêm experimentando ao longo de 30 anos. Aparentemente, em casos semelhantes, outros tipos de protocolos são utilizados pela OMS, como o utilizado no documento recentemente publicado: Intrapartum Care for Positive Childbirth Experience, que inclui qualquer tipo de projeto de pesquisa quantitativa, incluindo estudos observacionais, e não está limitado ao escopo dos ensaios clínicos.
  5. É muito provável que as mudanças propostas enfraqueçam e perturbem o produtivo trabalho e os benefícios obtidos com a IHAC, que atualmente é desenvolvida em todos os cantos do mundo.
O que fizemos

Nossa aliança enviou inúmeras cartas e documentos à OMS e ao UNICEF e tivemos numerosas discussões com representantes dessas organizações. Também enviamos um memorando detalhado aos Representantes dos Estados Membros no Comitê Executivo da Organização Mundial de Saúde (OMS) antes da reunião de janeiro em Genebra. Enquanto participavam da reunião, vários dos nossos membros conversaram com os representantes da OMS e com os líderes da OMS e do UNICEF e, os informaram sobre as nossas preocupações.

Com base na avaliação das evidências e nas informações apresentadas pela nossa aliança, a OMS e o UNICEF parecem ter feito mudanças substanciais na proposta preliminar, incluindo a manutenção da ordem, do número e do conteúdo de cada um dos 10 Passos originais. No entanto, ainda existem muitas lacunas no alinhamento das nossas abordagens com as da OMS e do UNICEF.

Solicitamos que fosse adiada a publicação da proposta do Guia Operacional a fim de se ter mais tempo para mais conversas e melhorias. O plano original da OMS e do UNICEF era a publicação do Novo Guia em novembro de 2017. De acordo com uma comunicação recente, há uma nova data provável de publicação: final de março de 2018.

O que você pode fazer?

Se você apoia a continuação de uma revisão minuciosa e global deste tema, com o objetivo de encontrar o melhor para os bebês e suas mães, é fundamental que a OMS, o UNICEF e representantes de seu país na Assembleia Mundial da Saúde conheçam imediatamente as suas preocupações. O Guia Operacional poderá ser incluído em uma Resolução da Assembleia Mundial da Saúde que será apresentada para aprovação pelos Estados Membros na reunião de maio de 2018. A lista de delegados para 2017 pode ser vista aqui e pode ser útil para identificar e localizar delegados de cada país.

Você pode enfatizar alguns ou todos dos seguintes pontos e recomendações que continuamos promovendo nas nossas negociações com a OMS e o UNICEF:

  1. Conservar as diretrizes, os critérios, as ferramentas simplificadas de monitoramento e avaliação e os sistemas de pontuação como “globais”.
  2. Manter o modelo de curso de formação padronizado, para que possa ser usado ou adaptado em todo o mundo.
  3. Continuar com os credenciamentos, como parte do processo, com base em avaliações externas que incluam entrevistas com mães e sejam realizadas por especialistas.
  4. Congratular a indicação da OMS e do UNICEF de que manterão os níveis de cumprimento dos hospitais em 80% do padrão.
  5. Agradecer a indicação da OMS e do UNICEF de que manterá a ordem, o número e o significado original dos 10 Passos.
  6. Comemorar o fato de que o Código e o sistema de monitoramento interno sejam incorporados no Passo 1 sobre as políticas de alimentação infantil.
  7. Recomendar a revisão do texto utilizado no recuperado Passo 9, para esclarecer a responsabilidade da instituição para minimizar o uso de mamadeiras, bicos e chupetas. Incluir textos sobre riscos e a necessidade dos pais de receberem informações sobre as implicações de usar mamadeiras, bicos e chupetas.
  8. Continuar mantendo as práticas de segurança e de respeito no parto como um componente da IHAC.
  9. Incorporar linguagem motivadora ao longo do documento do Guia Operacional.
  10. Manter os recém-nascidos saudáveis ​​como sujeitos objeto da IHAC. Adotar um conjunto diferente de padrões em relação ao apoio da amamentação em recém-nascidos doentes ou prematuros, como o NEO-IHAN desenvolvido pela aliança de países nórdicos e Canadá.
  11. Incluir uma seção que trate dos aspectos éticos relacionados à realização de ensaios clínicos randomizados na pesquisa sobre amamentação.
  12. Incorporar uma sólida discussão sobre como os 10 Passos estão inter-relacionados em um todo global e constituem um programa abrangente de apoio à amamentação.

Agradecemos sinceramente a oportunidade de comunicação com a OMS e o UNICEF sobre esta questão importante e esperamos continuar a fazê-lo de forma fluida. Juntos podemos fortalecer as bases que sustentam a amamentação em todo o mundo.

Muito obrigado pelo seu apoio.

 

Sinceramente,

Trish MacEnroe, coordenadora da Rede Global Iniciativa Baby-Friendly para países industrializados e CEEIS (BFHI Network)

Elizabeth Sterken, co-presidente da International Baby Food Action Network (IBFAN)

Michele Griswold, presidente da International Lactation Consultant Association (ILCA)

Ann Calandro, presidente da La Leche League International (LLLI)

Felicity Savage, presidente da World Alliance for Breastfeeding Action (WABA)

 

Traduzido por Alessandra Rivero Hernandez e Dolores Fernandez

Traduções adicionais desta comunicação estão disponíveis em inglês, francês, italiano e espanhol.

Nota do Editor: A International Consultation Association Lactation gostaria de aplaudir os esforços de advocacia importantes de nossos representantes, Kathleen Marinelli, Joan Dodgson e Linda Smith, que trabalharam dentro desta colaboração.

ILCA, ABM, and WABA Joint Statement for the Commission on the Status of Women (CSW62)

ILCA participates with the Commission on the Status of Women (CSW), a functional commission of the United Nations Economic and Social Council (ECOSOC). It is a global policy-making body dedicated exclusively to promoting gender equality and the empowerment of women.

Every year, representatives of Member States, United Nations entities and non-governmental organizations in consultative status with ECOSOC gather at United Nations Headquarters in New York for the Commission’s annual session. This year, CSW62 takes place from 12-23 March. The theme for this year’s session is “Challenges and opportunities in achieving gender equality and the empowerment of rural women and girls.”

Attending CSW is an opportunity for ILCA to influence policy makers and governments, and to network with other organizations working toward similar goals. ILCA’s UN Liaisons, Geri Fitzgerald and Lisa Mandell, in collaboration with the Academy of Breastfeeding Medicine (ABM) and World Alliance for Breastfeeding Action (WABA), developed the following statement to distribute at CSW. This statement was further ratified by 1000 Days, Helen Keller International, International Baby Food Action Network (IBFAN), and Training and Assistance for Health and Nutrition Foundation (TAHN). Lisa Mandell attended CSW62 on 12-13 March and distributed the statement to many people; she was also able to bring breastfeeding and the need for skilled lactation support to the attention of speakers in several sessions, and she attended a Town Hall meeting with the UN Secretary-General, António Guterres. Geri Fitzgerald will attend CSW62 on 19 March to further ILCA’s networking by attending sessions sponsored by the WHO, UNAIDS, UN Women, Zambia, Denmark and PAHO.

The statement is below:

Empowerment of rural women and girls: How breastfeeding and skilled lactation support can empower rural women and improve health outcomes

Breastfeeding empowers women, including rural women and girls, to provide their children with optimal nutrition, improve child survival, and promote long-term health for both mother and child. Breastfeeding is the foundation of life.

There are two important and relevant documents which address the means to empower women and girls in this context:

  1. The Draft Agreed Conclusions prepared by the CSW62 Bureau highlights importance of implementing economic and social policies for the empowerment of rural women and girls. This document identifies the critical need to increase access to quality care before, during, and after childbirth.
  2. The Sustainable Development Goals include ensuring access by infants to safe, nutritious, and sufficient food (2.1); ending all forms of malnutrition and achieving targets on stunting and wasting in children under 5 years of age (2.2); addressing the nutritional needs of lactating women (2.2); reducing neonatal mortality (3.2); ensuring access to reproductive health-care services (3.7); and recognizing and valuing unpaid care provided by women and girls (5.4).

It is critical that breastfeeding and skilled lactation support are included in policies designed to achieve the above goals.  As the cornerstone of any comprehensive policy designed to improve the health and well-being of childbearing women and their children, breastfeeding can save lives and improve long-term health of the entire community.

Breastfeeding according to World Health Organization (WHO) recommendations has the capacity to save over 800,000 infant lives per year. Human milk is always clean, readily available, requires no access to fuel, clean water, or electricity, and is environmentally sustainable. Human milk provides reliable and sustainable nutrition for optimal growth of infants, while protecting the infant from infection and food insecurity in risky environments. An infant who is not breastfed for the first 6 months of life is 14 times more likely to die compared with an infant who receives human milk only. Infants not breastfed have a higher risk of many diseases. Infants whose mothers lack adequate breastfeeding support are at risk for premature weaning. Women who breastfeed for a shorter duration or not at all are at higher risk of many diseases, and they experience shorter birth intervals with resulting negative health outcomes.

These negative consequences of not breastfeeding have a higher impact among rural women and their children.

  • Rural women have poor access to health care. When health care providers offer skilled support for breastfeeding, initiation and duration rates increase.
  • Rural women and their infants are at increased risk of disease, and have less access to fuel, clean water, and electricity needed to prepare alternatives to human milk.

By improving health outcomes from day 1, the goal of empowering women and girls is attainable.  Lactation support to improve breastfeeding initiation and duration is a critical step toward reaching this goal.  Actions to advance breastfeeding as part of nutrition, food security and poverty reduction strategies galvanize efforts to achieve sustainable development goals.

Therefore, we recommend and urge governments, health ministers and political leaders to invest in the future of rural women and girls by developing policies for sustainable practices that increase access to quality care, including skilled breastfeeding support, before, during, and after childbirth.

Introducing ILCA’s New Executive Director: Jessica Lytle

The Board of Directors of the International Lactation Consultants Association is pleased to announce the hiring of a new Executive Director, Jessica Lytle.

Some of you may have had the opportunity to meet Jessica at a conference or work with her on a committee as she has been on staff with ILCA for the last five years in a number of capacities.

She was chosen based on her strategic organizational skills, her knowledge of the organization, and her deep commitment to the mission and vision of ILCA, including the advancement of the IBCLC profession worldwide.

Jessica brings nearly 20 years in non-profit management experience, including serving as ILCA’s membership manager and assistant executive director. She is particularly committed to ensuring ILCA’s global impact and to working towards the organizational mission.

In her past roles at ILCA, she was instrumental in the shift to equity pricing for membership, which has increased ILCA’s accessibility to lactation supporters in lower-resource countries around the globe. She also played a key role in the initial development of the Global Partners Program.

Jessica has recently served as ILCA’s interim executive director. During this time, she has already begun the process of streamlining both staff and volunteer operations, ensuring that time and talent are spent as efficiently and effectively as possible.

Jessica lives in North Carolina. When she is not supporting ILCA, she spends her time with her husband and two boys on the baseball field.

We hope you will join us at the upcoming ILCA conference in Portland, Oregon, United States where you will have the opportunity to meet Jessica face-to-face.

Submissions OPEN for 2018 Journal of Human Lactation Photo Contest

 

Every year, the Journal of Human Lactation (JHL) hosts a photo contest for the coveted cover spot on each edition. The JHL is a quarterly, peer-reviewed journal publishing original research, insights in practice and policy, commentaries, and case reports relating to research and practice in human lactation and breastfeeding. The annual photo contest is your opportunity to contribute to the journal and highlight your community.

The photo(s) on JHL’s cover are changed annually. JHL is your journal, and we want to feature your photos!

The photo(s) portray the broad field of human lactation, including the IBCLC helping new families (in a wide variety of scenarios), breastfeeding in various cultural contexts around the globe, and the science of lactation.

GUIDELINES:

  • Keep the photo simple: Focus on the subject while limiting background items and distractions. Frame your photo carefully for full effect.
  • High Resolution and Size: Photos must meet the MINIMUM specifications:
    • A jpeg file
    • At least 300DPI
    • At least 4″ tall and wide.
  • If selected, photo consent is required for all persons in photo: If a recognizable person is in the photo and your image is selected, (e.g., the face of a parent/baby/clinician etc.) you will be asked to submit a signed photo consent form. If you do not have a standard photo consent form, we can provide one to you if your photo is chosen.

Please do not send photos of lesser size and resolution. Photos that do not meet these specifications cannot be considered.

SUBMISSION INFO:

  • Deadline is 1 September 2018: NO EXCEPTIONS
  • Include your name, the photo consent, and if you are not the photographer, the name of the photographer, and full contact information, preferably with a second email address.
  • The photographer will need to sign non-exclusive copyright – in other words, allowing JHL to use the photo, but the photographer is free to use it elsewhere as one chooses.
  • You will receive an auto response email to confirm your submission.

IBCLC Day: Celebrating YOUR Contribution to World Health through Lactation

 

Breastfeeding education. Home lactation support. Helping breastfeeding and chestfeeding families in clinics and hospitals. Human milk research. Emergency and disaster support for displaced families with infants. These are just a few of the ways that you as International Board Certified Lactation Consultants® (IBCLCs®) are contributing to world health outcomes by sharing your expertise.

On Wednesday, 7 March, we welcome your community to celebrate YOU by thanking IBCLCs.

We hope you will also take this opportunity to celebrate the IBCLCs that have made a difference in your life, through mentorship, community, or support.

Show your IBCLC pride! Starting now, use our IBCLC Day frame on your Facebook image to help build recognition for your profession.

 

Find the IBCLC Day frame here. Find IBCLC Day images for you and your community to share here.

 

We have also welcomed code-compliant organizations that would like to provide special offers to IBCLCs for #happyIBCLCday to do so on our event page. Feel free to check out what they have shared with you here. We also hope that you will share with us what you are doing in your local community to celebrate!

#happyIBCLCday

Honor IBCLCs Locally and Globally with the IBCLC Care Award

 

As the international professional organization for the International Board Certified Lactation Consultant® (IBCLC®), we know that those who have achieved this credential provide valuable expertise in the field of lactation care.

IBCLCs globally provide skilled support to individual caregivers in their efforts to breast/chestfeed. Because of the nature of this work, it is most effectively conducted on a local or regional level. We believe that IBCLCs deserve international acclaim for the differences that they are making in the lives of caregivers and their children, which is one of the reasons we host the IBCLC Care Award in conjunction with the International Board of Lactation Consultant Examiners® (IBLCE®).

This award honors Hospital-Based Facilities and Community-Based Agencies around the world that hire IBCLCs, have dedicated lactation programs and show evidence of lactation projects that promote, protect and support breastfeeding.

In order to be awarded the IBCLC Care Award, Hospital-Based Facilities and Community-Based Agencies must provide the name of the IBCLC(s) on staff and a detailed program description, including goals, outcomes, and evidence. Hospital and Community Agency awardees are provided with a press release describing the IBCLC Care Award for distribution to their local media outlets. In addition, they are listed for two years in the IBCLC Care Directory, which is accessed by parents looking for quality lactation support services. When two years have passed, these groups are encouraged to re-apply with a new lactation project to continue being listed in the directory. Because the directory lists programs supporting IBCLCs from all over the world, it gives local programs credibility in their communities and internationally.

IBCLCs work in their communities to encourage the fundamental, incredible connection between a parent and his/her child. The IBCLC Care Award is one way to honor the work of IBCLCs, recognize the facilities and agencies that hire them, encourage others to benefit from their services and inspire a new generation of lactation professionals.

If you are interested in recognizing the work of IBCLCs on your staff in your hospital or community on a global scale, you can click here to learn more about the qualifications and complete the online application

Apply now! Applications will be accepted online from 15 January 2018 through 16 February 2018.

The award was created by International Board of Lactation Consultant Examiners® (IBLCE®) and International Lactation Consultant Association® (ILCA®). Learn more and apply here.

2018 IBCLC Care Awards Now Open

Let potential clients know that your Hospital-Based Facility or Community-Based Agency recognizes the role of the International Board Certified Lactation Consultant® (IBCLC®) in protecting, promoting and supporting breastfeeding by applying for the IBCLC Care Award.

The IBCLC Care Awards are promoted to new families and the general public which means your facility can enjoy the benefits of positive public relations in your community, including:

  • Enhanced attractiveness to potential patients
  • Competitive edge in recruiting lactation consultants, nurses, midwives, mother support counselors and other medical staff
  • General good will in the community by providing excellent care in helping new families reach their breastfeeding goals

Visit the IBCLC Care Directory to see which Hospital-Based Facilities are already benefiting from the IBCLC Care Award program!

Hospital-Based Facilities and Community-Based Health Agencies that staff currently certified IBCLCs can apply online to become a recognized IBCLC Care Award facility. Learn more about the qualifications and complete the online application here.

Apply now! Applications will be accepted online starting 15 January 2018 through 16 February 2018.

The award was created by International Board of Lactation Consultant Examiners® (IBLCE®) and International Lactation Consultant Association® (ILCA®). Learn more and apply here.

Top 10 JHL Posts of 2017

On topics ranging from the impact of breastfeeding on breast cancer to co-sleeping to human milk donation, our community tapped into the top-accessed resources of Journal of Human Lactation (JHL) more than 22,000 times last year.

As we wrap up 2017, we compiled this list of the year’s top ten most accessed JHL content. Planning on using research to guide your practice next year? Now is the time to join or renew your membership to ensure a full year’s access to next year’s new content. Once you join or renew, you will also have online, on-demand searchable access to the full database of JHL research to find the evidence you need.

#10 Factors Distinguishing Positive Deviance Among Low-Income African American Women: A Qualitative Study on Infant Feeding

Cecilia E. Barbosa, Saba W. Masho, Kellie E. Carlyle, Maghboeba Mosavel

#9 Interventions to Improve Breastfeeding Self-Efficacy and Resultant Breastfeeding Rates: A Systematic Review and Meta-Analysis

Meredith Brockway, Karen Benzies, K. Alix Hayden

#8 Factors Influencing the Breastfeeding Practices of Young Mothers Living in a Maternity Shelter: A Qualitative Study

Rosann Edwards, Wendy E. Peterson, Joy Noel-Weiss, Cathryn Shearer Fortier

#7 Efficacy of an Osteopathic Treatment Coupled With Lactation Consultations for Infants’ Biomechanical Sucking Difficulties: A Randomized Controlled Trial

Juliette Herzhaft-Le Roy, Marianne Xhignesse, Isabelle Gaboury

#6 Breastfeeding Mode and Risk of Breast Cancer: A Dose–Response Meta-Analysis

Mishel Unar-Munguía, Gabriela Torres-Mejía, M. Arantxa Colchero, Teresita González de Cosío

#5 About Research: Qualitative Methodologies

Joan E. Dodgson

#4 Breastfeeding in Women Having Experienced Childhood Sexual Abuse

Constanze Elfgen, Niels Hagenbuch, Gisela Görres, Emina Block, Brigitte Leeners

#3 The Atlantic Divide: Contrasting U.K. and U.S. Recommendations on Cosleeping and Bed-Sharing

Helen L. Ball

#2 An Adoptive Mother Who Became a Human Milk Donor

Beatriz Flores-Antón, Nadia Raquel García-Lara, Carmen Rosa Pallás-Alonso

#1 Systematic Review of Evidence for Baby-Friendly Hospital Initiative Step 3 Prenatal Breastfeeding Education

Kathryn Wouk, Kristin P. Tully, Miriam H. Labbok