Breastfeeding, from our previous communications in “CHILD HEALTH AND YOU”, offers a plethora of benefits of ALL: Child, Mother, Family, Society, Nation and the World. Breastfeeding also holds the promise for controlling the evolving Public Health menace posed by the emerging scourge of Non-communicable Diseases (NCDs) in adulthood. Breastfeeding is, therefore, a low-cost high-impact ubiquitous intervention for improved public health across ages and generations. Unfortunately, breastfeeding practices have been unsatisfactory falling short of the recommendations that facilitate and possibly guarantee better breastfeeding rates and the attendant benefits.
In order to address this long standing challenge, and recognizing the peculiar role and impact of health facilities and their practices concerning breastfeeding, the World Health Organization (WHO) and UNICEF in 1989 issued a Joint Statement in the document: “Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services’. This document contained ‘The Ten Steps to Successful Breastfeeding’, the thrust and focus of this current presentation.
These are expressly detailed in the Joint UNICEF/WHO document and represent the foundations of the Baby-Friendly Hospital Initiative (BFHI). The ‘Ten Steps’ address various aspects of practices in hospitals and maternity services which are capable of influencing and affecting breastfeeding practices in the community. Each step has proven a positive impact on breastfeeding practices. Implementing any two or more of the ‘Ten Steps’ has greater impact on improving breastfeeding practices than implementing just any one step. Also, omitting any one or more of the ‘Ten Steps’ reduces the impact the BFHI has on breastfeeding practices. Therefore, ALL the ‘Ten Steps’ must be implemented to protect, promote and support breastfeeding. The steps involve the strategies to support mothers before, during and after delivery to facilitate the successful initiation, establishment and maintenance of breastfeeding.
The Joint UNICEF/ WHO Statement on the ‘Ten Steps to Successful Breastfeeding’ includes:
Every Facility Providing Maternity Services and Care for newborn infants should implement the following steps:
STEP ONE: Have a written breastfeeding Policy that is routinely communicated to all health care staff.
This step ensures that health facilities take concrete steps to address the critical determinants of breastfeeding practices and that policies are formulated, expressly documented and made available to staff of the facility. They should be printed and conspicuously pasted at various locations, spots and boards in the facility for the attention of staff, clients patronizing the facility and possibly, the general public. The policies should be officially and regularly communicated to the staff of the facility. Having a written Breastfeeding Policy assures consistency in the hospital practices that help mothers to breastfeed successfully and the responsibilities expected to be discharged by staff of the facility towards the mothers in this respect. Frequent staff transfers, redeployment or disengagement will have minimal effect on existing hospital practices once the Breastfeeding Policies are clearly documented for the records and for consistent implementation for continuity.
Written policies also provide verifiably available templates for monitoring and evaluating the efforts and progress of facilities in their performance concerning protection, promotion and support for breastfeeding.
Step Two: Train all Health Care Staff in Skills Necessary to implement this Policy
It is a tall assumption to imagine or believe that every health worker or healthcare staff is quite knowledgeable in the information, skills and techniques required for successful breastfeeding. Also, in a given facility, the different healthcare staff are of different professional levels with varying knowledge, skills and competences and, therefore, will have different abilities and capacities to support mothers in their efforts to breastfeed successfully. This step ensures that all healthcare staff also builds a pool of potential trainers who, in turn, are capable of training others: ‘Training of Trainers’ intervention. The step also provides for ‘Retraining’ of trained healthcare staff to guarantee that trained staff remain conversant with known skills, standards and techniques in addition to exposing them to new and emerging advances concerning the science and practice of breastfeeding.
STEP THREE: Inform all pregnant women about the benefits and management of breastfeeding.
It is also a costly assumption to imagine or believe that every mother has the right information, skills and techniques to breastfeed successfully. It is even a taller assumption to believe that having breastfed previously, a woman has the appropriate information, skills and techniques necessary for capability to breastfeed successfully. Informing women of the benefits of breastfeeding has the potential of winning their commitment to ensure that they succeed with the feeding practice even if they are faced with breastfeeding difficulties. Endowing women with the appropriate skills and pleasurable, fruitful and with minimal breastfeeding difficulties. Breastfeeding is a process that has to be learnt, practiced and managed appropriately to achieve the desired objective and impact on child health, survival, protection and development.
STEP FOUR: Help Mothers Initiate Breastfeeding within half an hour of birth.
In the past, it was generally felt that a mother who had ‘laboured’ for several hours needed to be allowed sufficient time to ‘rest’ after delivery of her baby. She should, therefore, be allowed a few days to recuperate before commencing breastfeeding her baby. Also, the baby who ‘laboured and journeyed’ through the ‘birth canal’ should also be spared the further stress of commencing breastfeeding for the first few days after birth. Worse still is the dangerous belief that the first yellowish milk produced by the mother, called colostrum, is ‘poisoned milk’ and, therefore, bad for the baby and hence discarded. The production of colostrum lasts a few days. Therefore, for more reasons than one, baby and mother do not resume their ‘breastfeeding coupling’ relationship for the first few days after birth and delivery respectively. So, the baby is fed with some preparations in the interval: glucose-water, infant formula, etc. These preparations fed to the baby before breastfeeding commences are called ‘Prelacteals’ and are not necessary for successful breastfeeding and optimal infant and young child feeding. Feeding newborn babies undermines the successful establishment of breastfeeding and, therefore, should not be encouraged; indeed, it should be actively discouraged.
Mothers and their babies should be enabled to enter into their ‘breastfeeding coupling’ relationship soon after birth as is practically feasible, and certainly, within the first half-hour of the birth of the babies. This step, (Step Four) seeks to support mothers and help them to initiate and commence breastfeeding within thirty minutes of the delivery of their babies. This requires a lot of skills and techniques on the part of healthcare staff to be able to achieve this objective which is necessary for proper management of breastfeeding. Early initiation of suckling and breastfeeding confers a plethora of benefits on the mother and her newborn baby. Through well-documented hormonal interactions, the mother is prevented from the problems and dangers of difficult bleedings after delivery called ‘Postpartum Haemorrhage’ which is a major determinant of the persistently high Maternal Mortality Ratio in most developing countries; an unacceptable persistent scourge in Nigeria! This early initiation of breastfeeding also helps the mother’s uterus to return to near the state before pregnancy and be well-prepared and ready for the next pregnancy. This effect on the uterus is referred to as ‘Involution’. Initiating breastfeeding this early also helps to set in motion the release of the relevant hormones that are involved in the successful establishment of lactation. Also, the early initiation of suckling guarantees the bonding between mother and baby which at this early and critical time is necessary for normal psychological development and personality formation of the baby and growing child. The baby also receives the colostrum which is very rich in several factors, anti-infective factors, which protect the baby against several communicable and preventable infections prevalent in early childhood with their attendant morbidity and mortality. This step is, indeed, a critical step among the ‘Ten Steps’ to successful breastfeeding.
STEP FIVE: Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
This step requires that during pregnancy and before delivery, and even before pregnancy, mothers should be taught how breastfeeding works: the anatomy of the breasts and the physiology of lactation in very simple, clear and understandable client-friendly terms. This breast-feeding education is continued into the postnatal period to support the ‘breastfeeding couple’. Essentially, the mother is enabled to build confidence in her ability and capacity to breastfeed through the unmistakable understanding of the parts of her breasts, her positioning in readiness for breastfeeding, the positioning and attachment of the baby to her breasts, the effective suckling skills and techniques and how the hormones that initiate, establish and maintain lactation work in the body. With this education, mothers are more relaxed, more psychologically primed and demonstrate better practical ability in breastfeeding. Mothers are also taught the skills and techniques to manually express milk from their breasts and feed their babies with the ‘Expressed Breast Milk’ (EBM) in case they have to be separated from their infants for some reasonable length of time during the day. Manual expression may also be practiced if baby cannot, for whatever reasons, be suckled at the breasts soon after delivery. This may be the case if the baby is born premature or is quite sick after birth. The manual expression of the breasts maintains lactation physiology and also prevents breastfeeding difficulties including, among others, painful breasts, breast engorgement and poor milk production and complaints of ‘Milk Insufficiency’. The EBM in a cup with tightly-fitted cover remains sterile at room temperature for 6-8 hours because it contains several factors that protect it against infection and possible unhygienic handling by care-providers. With a refrigerator, fridge-freezer and deep freezer, the EBM remains sterile for much longer and should never be thawed by heating before use; the stored EBM should be allowed to thaw at room temperature and fed to the baby with cup or spoon; never with a feeding-bottle! This Step Five is particularly useful for mothers who have to be separated from their babies due to illness, work or unavoidable short travels and other such difficult circumstances. As much as is feasible and practicable, baby and mother (the ‘breastfeeding couple’) should never be separated for optimal child care and child-rearing practices! It is incorrectly perceived that EBM is not safe in the hands of house-helps and such child-minders because of a possible propensity for contamination. The EBM is very rich in fat content which favour the intrinsic production of Free Fatty Acids which, in turn, confer antibacterial and bactericidal activity on it thereby preventing its infection. This protection is better with manually obtained EBM compared with that obtained by Breast Pump which is less preferred. Also incorrect is the perception that once the milk is expressed and already out of the mother’s breasts, it goes sour and no longer fit for consumption by the baby. EBM properly stored in a cup with tight-fitting cover remains safe, nutritious and free from infection depending on the storage method: 6 – 8 hours at room air, 24 hours in a refrigerator and at least 3 months in freezer.

In this presentation, we have reviewed Step One to Step Five of the ‘Ten Steps to Successful Breastfeeding’ which must be part of a written ‘Breastfeeding Policy’ to be conspicuously displayed in every facility providing maternity services and care for newborn babies. Through properly structured and facilitated training and retraining, ALL healthcare staff should have their capacities built-up in the knowledge, skills and techniques required for the successful implementation of the steps. This is a sine qua non for the impact of the BFHI as a strategy to achieving improved child survival, health, protection and development by protecting, promoting and supporting breastfeeding. In a future publication of ‘CHILD HEALTH AND YOU’, the remaining five steps will be reviewed and, therefore, the populace should be on the alert for the ‘Must-Read’.
Professor C.O. Eregie
Professor of Child Health and Neonatology, Institute of Child Health, University of Benin, Benin City.
Consultant Paediatrician and Neontologist, University of Benin Teaching Hospital, Benin City.
‘CHILD HEALTH AND YOU’, a Weekly Thursday Feature, is a collaborative initiative between the Institute of Child Health, University of Benin, and the Bendel Newspapers Company Limited (BNCL), Benin City.

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