| Reach |
The absolute number, proportion, and representativeness of individuals willing to participate in a given initiative, intervention, or program. |
About 25% of the total number of live hospital births in Brazil occur in hospitals-accredited as baby-friendly 5252. Lamounier JA, Santiago LB, Romano MCC, Silva RP, Araujo RG, Chaves RG. Public health policies and breastfeeding: outcomes related to the Baby-Friendly Hospital Initiative in Brazil. World Nutr 2021; 12:83-135.. Of the 3 million births occurring in Brazil per year, 98% occur in hospitals, which is a window of opportunity for all children to benefit from the practices recommended by the BFHI. |
The reach of the EAAB has not been monitored during the implementation; therefore, the percentage of the target population reached by the strategy is unknown. |
| Effectiveness |
The impact of an intervention on important outcomes. |
Despite the low reach of the Brazilian BFHI, several national studies point to the impact of the BFHI on indicators such as breastfeeding in the first hour of life, exclusive breastfeeding for the first six months, reduction of pacifier use, and consequent increase of exclusive breastfeeding duration 5252. Lamounier JA, Santiago LB, Romano MCC, Silva RP, Araujo RG, Chaves RG. Public health policies and breastfeeding: outcomes related to the Baby-Friendly Hospital Initiative in Brazil. World Nutr 2021; 12:83-135.,5353. Pérez-Escamilla R, Martinez JL, Segura-Pérez S. Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review. Matern Child Nutr 2016; 12:402-17.,5454. Venancio SI, Saldiva SRDM, Escuder MML, Giugliani ERJ. The Baby-Friendly Hospital Initiative shows positive effects on breastfeeding indicators in Brazil. J Epidemiol Community Health 2012; 66:914-8.,5555. Braun MLG, Giugliani ERJ, Soares MEM, Giugliani C, Oliveira AP, Danelon CMM. Evaluation of the impact of the Baby-Friendly Hospital Initiative on rates of breastfeeding. Am J Public Health 2003; 93:1277-9.. Therefore, the Brazilian BFHI is an example of difficulties incorporating evidence into health services. |
One important challenge to measure EAAB’s effectiveness is the difficulty of health professionals in monitoring breastfeeding and complementary feeding indicators. Although Brazil has the SISVAN, the coverage of monitoring children 0 to 2 years old was only 5.1% in the 382 municipalities that had greater adherence to the EAAB. Thus, only a few studies have analyzed the impact of the EAAB on breastfeeding and complementary feeding indicators. A study conducted to assess the effectiveness of using a manual to support the tutor implementing the EAAB found a positive impact on complementary feeding indicators, such as minimal food diversity and adequacy of children’s diet, and no effect on exclusive breastfeeding in children under six months 5858. Relvas GRB, Buccini G, Potvin L, Venancio SI. Effectiveness of an educational manual to promote infant feeding practices in primary health care. Food Nutr Bull 2019; 40:544-61.. Therefore, more studies need to be conducted to fill this important gap, about whether EAAB can impact infant and young children’s nutritional outcomes. |
| Adoption |
The absolute number, proportion, and representativeness of: (a) settings and (b) intervention agents (people who deliver the program) who are willing to initiate a program. |
Between 1992 and 2010, 322 hospitals were accredited in the BFHI. However, after 2005, a deacceleration of the number of qualifying hospitals was observed, and others were discredited. In 2021, Brazil had only 302 accredited-hospitals 5252. Lamounier JA, Santiago LB, Romano MCC, Silva RP, Araujo RG, Chaves RG. Public health policies and breastfeeding: outcomes related to the Baby-Friendly Hospital Initiative in Brazil. World Nutr 2021; 12:83-135.. Although present in all 26 Brazilian states and the Federal District, most accredited hospitals are in the Northeastern Region (111), followed by the Southeastern Region (78), the Southern Region (55), the Central-Western Region (34), and the lowest number in the Northern Region (24), which points to important regional inequalities 5252. Lamounier JA, Santiago LB, Romano MCC, Silva RP, Araujo RG, Chaves RG. Public health policies and breastfeeding: outcomes related to the Baby-Friendly Hospital Initiative in Brazil. World Nutr 2021; 12:83-135.. In addition, less than 10% of hospitals with maternity wards in the country are accredited in the BFHI. There is a consensus among policymakers, managers, health professionals, and researchers that the addition of the other criteria, in addition to those established globally, has hindered the adoption and scale-up of the BFHI in Brazil 5252. Lamounier JA, Santiago LB, Romano MCC, Silva RP, Araujo RG, Chaves RG. Public health policies and breastfeeding: outcomes related to the Baby-Friendly Hospital Initiative in Brazil. World Nutr 2021; 12:83-135.. The process of accreditation of hospitals by the BFHI has not been uniform, with variations depending on the support of state and municipal authorities and hospital management, in particular the availability of financial resources for the entire process of qualifying the hospital 5252. Lamounier JA, Santiago LB, Romano MCC, Silva RP, Araujo RG, Chaves RG. Public health policies and breastfeeding: outcomes related to the Baby-Friendly Hospital Initiative in Brazil. World Nutr 2021; 12:83-135.. |
According to data from the EAAB Management System, from 2013 until 2019, 5,959 tutors were trained, 3,290 primary health teams/clinics received workshops, and 48,640 primary health professionals participated in training activities 5959. Bortolini GA. Avaliação da implementação da Estratégia Amamenta e Alimenta Brasil (EAAB). Brasília: Universidade de Brasília; 2017.. However, according to the EAAB monitoring system only 382 of the 5,575 Brazilian municipalities registered workshops between 2015 and 2019. In addition, considering the number of existing primary health teams/clinics and the number of tutors trained, the possible coverage of the EAAB in the country is 9.42%, with the Central-Western and Northern regions exhibiting the greatest possibility of coverage and the Northeastern Region having the least possibility to cover the primary health teams/clinics 5959. Bortolini GA. Avaliação da implementação da Estratégia Amamenta e Alimenta Brasil (EAAB). Brasília: Universidade de Brasília; 2017.. |
| Implementation |
At the setting level, implementation focuses on fidelity to an intervention, which is the extent to which the program is implemented consistently across different settings, staff, and patients. It also includes adaptations made and costs from multiple stakeholder perspectives. |
Special attention must be paid to BFHI accreditation, i.e., fidelity based on compliance with the “Ten Steps” and the additional three core criteria. The assessment of compliance with the criteria has been evaluated through a complex system established by the Brazilian Ministry of Health, which includes the evaluation stages for accreditation and triennial reassessments, both conducted by external trained evaluators, and annual self-monitoring of maternity hospitals. The self-monitoring conducted between 2010 and 2015 by 143 accredited hospitals observed greater than 70% adherence for most criteria 5050. Santos EKA. Implementação da Iniciativa Hospital Amigo da Criança: impacto, avanços e desafios. In: Venancio SI, Toma TS, editors. Promoção, proteção e apoio ao aleitamento materno: evidências científicas e experiências de implementação. São Paulo: Instituto de Saúde; 2019. p. 105-36. (Temas em Saúde Coletiva, 26).. However, the external reassessments conducted in 2015 found a lower percentage of compliance with some criteria, such as mother-friendly care and breastfeeding in the first hour of life (Step 4), both below 50% 5050. Santos EKA. Implementação da Iniciativa Hospital Amigo da Criança: impacto, avanços e desafios. In: Venancio SI, Toma TS, editors. Promoção, proteção e apoio ao aleitamento materno: evidências científicas e experiências de implementação. São Paulo: Instituto de Saúde; 2019. p. 105-36. (Temas em Saúde Coletiva, 26).. The same was identified in the Birth in Brazil research, in which breastfeeding at birth was considered low, even in accredited-BFHI hospitals (24% offered breast at delivery room and 56% were breastfed within the first- hour) 5656. Moreira MEL, Gama SGN, Pereira APE, Silva AAM, Lansjy S, Pinehrio RS, et al. Práticas de atenção hospitalar ao recém-nascido saudável no Brasil. Cad Saúde Pública 2014; 30 Suppl:S128-39.. Another implementation barrier is related to the budget availability of the Brazilian Ministry of Health to reimburse practices within the Brazilian BFHI; for example, accredited hospitals should receive 17% reimbursement for a vaginal delivery or 8.5% for a cesarean 5252. Lamounier JA, Santiago LB, Romano MCC, Silva RP, Araujo RG, Chaves RG. Public health policies and breastfeeding: outcomes related to the Baby-Friendly Hospital Initiative in Brazil. World Nutr 2021; 12:83-135.. In addition, the lack of financial resources to support the travel of the BFHI trained evaluators is a barrier to conducting the assessment, which can impact the quality of the BFHI program. |
Analysis of fidelity is an important challenge of the EAAB. Based on the certification criteria, from 2015 to 2019, only 189 primary health teams/clinics had achieved all the criteria, representing 1.8% of the total primary health teams/clinics of the 382 municipalities that registered any continuing education workshops in that same period (data from EAAB monitoring system) An additional challenge is that the EAAB does not define a priori intervention model (such as conducting groups or home visits), the time of the intervention (prenatal, postnatal period, or both), the professionals who must be involved in its delivery or its intensity, which makes the analysis of fidelity complex. On the one hand, there is greater flexibility for adaptations to local contexts; on the other hand, teams have not been supported to design their interventions based on evidence, which can compromise the quality of interventions when they are developed. Another barrier to implementation of the EAAB is the lack of financial resources from the Brazilian Ministry of Health to support its implementation 5757. Melo DS. Processo de implementação da Estratégia Amamenta e Alimenta Brasil: uma análise do caminho de impacto do programa [Masters Thesis]. São Paulo: Universidade de São Paulo; 2020.. In 2013, the fund-to-fund transfer for food and nutrition interventions was revised and was an important advance to support the implementation of EAAB in municipalities with more than 150,000 inhabitants. However, state and municipal managers find it difficult to use these funds, and many times they have not been used 7474. Reis C. Avaliação da utilização do repasse fundo a fundo para estruturação e implementação das ações de alimentação e nutrição. Brasília: Universidade de Brasília; 2015.. Through Ordinance n. 3,297/2020, for the first time, the Brazilian Ministry of Health transferred resources to municipalities that had started holding EAAB workshops. A third barrier of EAAB implementation is the lack of institutionalization as municipalities can choose whether or not they want to roll out EAAB. Therefore, political will is critical to the implementation of EAAB at the municipal level 5757. Melo DS. Processo de implementação da Estratégia Amamenta e Alimenta Brasil: uma análise do caminho de impacto do programa [Masters Thesis]. São Paulo: Universidade de São Paulo; 2020.. |
| Maintenance |
The extent to which: (a) behavior is sustained six months or more after treatment or intervention; and (b) a program or policy becomes institutionalized or part of the routine organizational practices and policies. Includes proportion and representativeness of settings that continue the intervention and reasons for maintenance, discontinuance, or adaptation. |
The sustainability of BFHI in Brazil is a critical aspect since 23 hospitals were discredited as of 2005 5252. Lamounier JA, Santiago LB, Romano MCC, Silva RP, Araujo RG, Chaves RG. Public health policies and breastfeeding: outcomes related to the Baby-Friendly Hospital Initiative in Brazil. World Nutr 2021; 12:83-135.. In addition, the percentages of noncompliance with the Ten Steps and additional criteria identified in the self-monitoring and external reassessments indicate difficulties in the institutionalization of the evidence-based practices recommended by the BFHI in the routine of maternity hospitals 5252. Lamounier JA, Santiago LB, Romano MCC, Silva RP, Araujo RG, Chaves RG. Public health policies and breastfeeding: outcomes related to the Baby-Friendly Hospital Initiative in Brazil. World Nutr 2021; 12:83-135.. |
Unfortunately, after EAAB certification, the primary health teams/clinics have not been monitored. Therefore, without improving mechanisms of monitoring and quality, the sustainability of EAAB is uncertain. |
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ESPIN: Public Health Emergency of National Importance.