IHAN Initiative: what it is and how it promotes breastfeeding

The Initiative for the Humanisation of Birth and Breastfeeding Care (IHAN) is part of a global effort called the Baby-Friendly Hospital Initiative (BFHI), established by the World Health Organisation (WHO) and the United Nations Children's Fund (UNICEF) in 1991.

The original name, BFHI, translates as “Baby-Friendly Hospital Initiative”, but in Spain it was changed to IHAN because some healthcare centres had not yet obtained accreditation and the previous name might have been awkward for them.

History of the IHAN initiative

This initiative began after the University Hospital of San Diego, in California, changed its maternity practices based on the recommendations of groups of mothers who promoted natural breastfeeding. They stopped using practices such as placing babies in cots away from their mothers, setting feeding schedules instead of allowing breastfeeding on demand, and avoiding the use of dummies or bottles without reason.

This led to greater satisfaction among mothers and a significant increase in breastfeeding rates, which had previously been very low. This experience was shared with other professionals through courses and workshops, and eventually the World Health Organisation (WHO) and UNICEF asked them to compile what they had learned, which became the “10 steps to successful breastfeeding”. To encourage other hospitals to follow these steps, the BFHI initiative was created as a recognition of the quality of medical care.

In some countries, such as those in Scandinavia and some Balkan republics, most maternity units hold the IHAN accreditation. However, in countries such as Spain, France, Italy or Germany, the adoption of this initiative has been slower, with fewer than 5% of centres meeting these standards.

Later, this initiative was extended to health centres, where mothers who breastfeed continued to be supported after giving birth. In Spain, this began in 2011 and was called IHAN Health Centres (CS-IHAN). Health centres must meet 7 additional steps, on top of other requirements.

Benefits of IHAN accreditation

IHAN accreditation in centres and hospitals has had a positive impact in several areas, which in turn has improved the quality of care as follows:

• Users, who include pregnant women, women in labour, mothers and families, are more satisfied with the care they receive.
• Professionals have learned a great deal during the accreditation process and feel proud of their work. Working as a team involves frequent meetings and collaboration.
• The satisfaction of professionals and users creates an empathetic atmosphere that makes care more pleasant.
• Breastfeeding rates have improved significantly. For example, there has been an increase in breastfeeding percentages from birth to the first year of life and in the average duration of breastfeeding among the babies cared for at the Moncada Health Centre before and after the accreditation process.

IHAN hospitals: process and accreditation

The accreditation process consists of 4 stages:

• Discovery (1D): In this phase, accreditation is applied for, a self-assessment is carried out and a Breastfeeding Committee is set up.
• Development (2D): During this stage, a breastfeeding policy for the centre is drafted and approved. Breastfeeding-related documents are prepared for mothers, such as action protocols, training plans for professionals and antenatal education, and a coordination plan between the Maternity Unit and the Health Centre. Surveys are also carried out to assess breastfeeding prevalence.
• Dissemination (3D): This is where the training plan is implemented and breastfeeding workshops are held.
• Designation (4D): In this phase, all the plans are put into action, a new self-assessment is carried out and additional surveys are conducted to assess prevalence. An external assessment is also carried out to ensure that the requirements are met. Once this stage has been passed, the hospital or primary care centre receives the IHAN accreditation and recognition.

The IHAN website provides more specific details about the requirements for passing each phase, the necessary documentation and the training plans. As of March 2023, 20 hospitals had been accredited in Spain and 131 were in the process of accreditation, as well as 15 IHAN Health Centres and 287 in process.

IHAN accreditation for hospitals

To obtain accreditation, hospitals must comply with the “10 steps to successful breastfeeding” and meet 4 other additional requirements.

Step 1. Breastfeeding policy

The hospital will have a breastfeeding policy that will be known to all employees. This policy summarises the 10 steps, compliance with the marketing Code and other requirements.

Step 2. Staff training

Medical and nursing staff will receive specific training according to their role. This includes a full course for those caring for pregnant women, women in labour and newborns, another basic course for the rest of the medical and nursing staff, and an elementary course for porters, assistants and other workers.

Step 3. Information for pregnant women

Pregnant women will receive information about birth and breastfeeding before week 32, either at the hospital where they give birth or at their health centre.

Step 4. Skin-to-skin contact and first breastfeed

Immediate skin-to-skin contact between mother and newborn will be promoted, postponing other interventions such as weighing the baby or administering treatments, as long as mother and baby are clinically stable. In addition, the first breastfeed will be facilitated within the first hour of life.

Step 5. Support for establishing breastfeeding

Staff will provide support to mothers in starting and maintaining breastfeeding, helping them to overcome possible difficulties. The first feeds will be supervised, paying special attention to mothers with risk factors for stopping breastfeeding. Mothers will also be taught how to express and give milk if necessary.

Step 6. Avoiding supplements

No additional liquids or foods will be offered to the breastfed baby, unless they are clinically indicated and their need is documented in the medical records.

Step 7. Mother and baby together

Mother and baby will be together throughout their stay in the Maternity Unit, unless there are medical reasons to separate them. In cases of separation due to special care of the baby, every effort will be made for the mother to be as close to the baby as possible, encouraging skin-to-skin contact and the kangaroo method.

Step 8. Breastfeeding on demand

Breastfeeding on demand will be supported, helping mothers to recognise when the baby is hungry and when they need the breast for other needs such as comfort or sleep. Even in situations of separation for medical reasons, staff will be attentive to the baby's signs and will allow the mother to be close without a fixed schedule.

Step 9. Avoiding bottles, teats and dummies

Bottles, teats or dummies will not be used with breastfed babies in the Maternity Unit, and mothers will be advised to avoid them during at least the first weeks of life due to the risk of interfering with breastfeeding. If supplements are needed, they will be given in other ways, such as with a syringe, a cup or a spoon. In premature babies, a dummy can be useful for their development, but they will be encouraged to suckle directly from the mother's breast using the kangaroo method whenever possible.

Step 10. Discharge from the Maternity Unit

Coordination with health centres will be ensured to provide follow-up after discharge from the Maternity Unit, which should take place within the first 48-72 hours. If this is not possible, the Maternity Unit staff will handle the follow-up. Information will also be provided about workshops, breastfeeding support groups and other useful resources.

Breastfeeding record: A record will be kept of how each baby is fed when leaving the Maternity Unit, and the aim will be for at least 75% to be exclusively breastfed.

Compliance with the Code on the marketing of breast-milk substitutes

As in health centres, hospital professionals undertake not to promote, hand out samples of or advertise substitutes or their utensils. If a substitute needs to be given as a supplement or formula feeding, the hospital will provide it, but will not accept the industry supplying it free of charge; instead, the hospital will buy it at market price.

Quality care during birth

To obtain IHAN accreditation, the hospital must ensure care during birth in line with the guidelines of the Ministry of Health's Normal Birth Strategy. This includes constant companionship, choosing the position for giving birth and avoiding unnecessary routine practices such as enemas or episiotomies, among others.

Care for mothers who do not breastfeed

Mothers who do not breastfeed will receive professional and humane care of the same quality. Skin-to-skin contact, feeding on demand, rooming-in, among others, will be recommended and made available to them. In addition, they will be instructed on how to prepare infant formula safely.

IHAN accreditation for health centres

Step 1: Breastfeeding policy

The centre must have a written policy on breastfeeding. This policy is drawn up with the collaboration of all the staff and must be known on a mandatory basis by all professionals at the centre. In addition, users are informed about the existence of this policy. This policy acts as a set of “good practices” that guides care for pregnant women, mothers and children, especially with regard to the promotion and management of breastfeeding. This includes avoiding the interruption or supplementation of breastfeeding without a clear reason, avoiding prescribing incompatible medicines unless strictly necessary and respecting prolonged breastfeeding, among other practices. In fact, this policy covers all the later steps.

Step 2: Staff training

Training courses are held for all professionals at the centre, and at least 80% of the staff must complete them. The training is adapted to each professional's responsibility regarding breastfeeding care. This includes:

• A full theoretical and practical training course of at least 20 hours for staff directly involved in the care of pregnant women, mothers and small children. This includes midwives, paediatricians and paediatric nursing staff. In some centres, such as small practices, family doctors and community nurses may also be trained.
• A basic training course of 4-5 hours for family doctors and community nurses, with the aim of raising awareness of the importance of breastfeeding and how to manage situations such as maternal illnesses, breast problems and the use of safe medicines during breastfeeding.
• An elementary training course of 2 hours for the rest of the staff, such as porters, assistants, administrative staff and social workers. The aim is to raise awareness of the importance of breastfeeding and the need to refer to a breastfeeding consultation in an emergency, as well as managing the first early visit (see step 4).

Step 3: Information for pregnant women

This step consists of providing pregnant women and their families with information about the benefits of breastfeeding and how to carry it out. This includes immediate skin-to-skin contact, breastfeeding when the baby demands it, maintaining exclusive breastfeeding during the first 6 months and avoiding the use of teats and dummies during the first weeks. As well as providing this information in individual consultations, group sessions on maternal or antenatal education are organised, usually led by the centre's midwives. Attending these antenatal education courses improves breastfeeding rates compared with pregnant women who do not attend.

Step 4: Help with starting breastfeeding

This step involves a first visit to the mother and baby as soon as possible, ideally within 48-72 hours after discharge from the maternity unit. To do this, the centre must coordinate with the reference maternity unit to schedule this first appointment or inform the family about the need to come to the centre. Admissions staff must also be trained to manage this early appointment. During this first visit, breastfeeding is assessed, a good latch and milk flow are checked, skin-to-skin contact is encouraged and possible problems are detected so that they can start to be addressed. Additional visits will be scheduled according to breastfeeding needs.

Step 5: Support for maintaining breastfeeding

This step involves helping to maintain exclusive breastfeeding until the baby is 6 months old, at which point complementary feeding is introduced without the need for supplements with breast-milk substitutes. In addition, the mother is taught how to express milk if she has to be away due to work before the baby is 6 months old. Support is provided to maintain breastfeeding until 2 years of age or beyond, as long as both mother and child wish it. It is emphasised that breast milk remains highly nutritious, provides defences, and that frequent contact and the bond between mother and child contribute to psychomotor development. It is also highlighted that breast milk is rarely refused when children are ill, and that it acts as an excellent rehydration solution with probiotics and an effective painkiller in moments of pain, such as during vaccinations or blood tests.

Step 6: Encouraging a breastfeeding-friendly environment

At the health centre, breastfeeding is welcomed through posters, information leaflets and promotional activities. A private space is offered for mothers who prefer to breastfeed in privacy.

Step 7: Breastfeeding workshops and support groups

The health centre organises Breastfeeding Workshops led by health professionals, where mothers share their experiences and support each other in case of difficulties. In addition, it works with local or nearby breastfeeding support groups, involving health professionals in the centre's breastfeeding committee and receiving their cooperation in the workshops.

Improving breastfeeding indicators

During the accreditation process, two surveys are carried out (at the beginning and at the end) to assess breastfeeding rates in the population served by the centre. The aim is to demonstrate an improvement in these rates over time, including exclusive breastfeeding in newborns and infants aged 0 to 6 months, the introduction of complementary foods at 6 months and sustained breastfeeding at one and two years.

Compliance with the Code on the marketing of substitutes

The centre's professionals undertake not to promote, hand out samples of or advertise, directly or indirectly, breast-milk substitutes or utensils related to their preparation or administration, such as teats, bottles and sterilisers. Those responsible for the breastfeeding committee, the centre coordinator and the head of the health department sign a commitment to adhere to the Code.

Information about birth

The centre's professionals inform pregnant women about the possibility of receiving friendly care during birth, following the guidelines of the Ministry of Health's national normal birth strategy. This includes practices such as constant companionship, allowing mobility, avoiding unnecessary routine procedures, promoting skin-to-skin contact between mother and baby and avoiding unnecessary separation after birth.

Quality care for mothers who do not breastfeed

Mothers who choose not to breastfeed receive equally respectful professional and humane treatment. They are given information on how to feed the baby safely with infant formula and are guided on how to maintain an emotional bond with the baby, encouraging physical contact and loving care.

Design your Bottle ®

Conclusions on the IHAN initiative

In 1991, the IHAN initiative marked a fundamental milestone in medical care related to birth and breastfeeding. Over the years, this initiative has proved to be a beacon guiding healthcare centres towards adopting safer and more ethical practices in the care of mothers and newborns. Its strict rules and conditions have raised the standards of care, promoting the health and wellbeing of families around the world.

IHAN is not only a set of rules, but also a reminder of the importance of protecting and supporting mothers and babies at one of the most crucial moments of their lives. By following its guidelines, healthcare centres not only guarantee a more humane and compassionate approach to care, but also contribute to the development of healthier and happier future generations.

Bibliography on the IHAN initiative

1. iHAN. Initiative for the humanisation of birth and breastfeeding care. www.ihan.es
2. Ministry of Health. Quality Plan for the National Health System. IHAN. Quality in professional care at birth and breastfeeding. https://www.sanidad.gob.es/ organizacion/sns/planCalidadSNS/equidad/saludGenero/saludSexualReproduccion/IHAN.htm
3. J Aguayo et al. IHAN Quality in professional care at birth and breastfeeding. Ministry of Health, Social Policy and Equality.
4. iHAN. Manual for the IHAN accreditation of health centres. IHAN-Spain 2017.
5. A Urtasun, E Jareño, P García et al. Evolution of the factors that influence the start and maintenance of breastfeeding in a Health Centre over the last 10 years. 64th Congress of the AEP, Valencia 2016.
6. iHAN. Global criteria. IHAN-Spain 2021.
7. A Urtasun, E Jareño, X Albert et al. 12-year evolution of breastfeeding indicators and associated factors in an IHAN-accredited health centre. Acta pediatr esp 78 (3-4).
8. Albert i Ros X. Sources of information on Breastfeeding. 3rd Complete Training Course in Breastfeeding for health professionals. Hospital de Lliria, 20-22 February 2020.