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A First for Nicaragua: Private Sector Organization Certified as “Mother and Baby Friendly”

Breastfeeding, especially exclusive breastfeeding in the first months of life, is recognized around the world as the best feeding option for infants. The Baby-Friendly Hospital Initiative (BFHI), launched by UNICEF and the World Health Organization (WHO) in 1991, is a key international strategy to promote breastfeeding by certifying hospitals that comply with the “Ten Steps to Successful Breastfeeding,” a series of evidence-based practices that support and promote breastfeeding as part of prenatal and delivery care. Since the BFHI began, more than 15,000 facilities in 134 countries have been awarded Baby-Friendly status by demonstrating their compliance with the Ten Steps. 

Nicaragua has a long tradition in breastfeeding promotion, having begun national efforts to promote breastfeeding in the public health sector in the 1980s. The country enacted the necessary laws, and the government established strategic alliances with international, nongovernmental, and civil society organizations promoting breastfeeding. Over the past 12 years, the Nicaraguan Ministry of Health has taken the lead in implementing the Mother and Baby Friendly Health Units Initiative (MBFHI) in Nicaragua, a name which reflects the broader scope of this program to include aspects of care for both infant and mother, and public hospitals and health centers as well as regional offices of the Ministry of Health and rural community children’s centers run by the Ministry of the Family.

But what about the private sector?

Dr. Clelia Valderde, Director of Standards for the Ministry of Health, bestows the “Gold Award of Breastfeeding” to Dr. Bladimir Fornos, Director General of AMOCSA, for his leadership of AMOCSA’s certification process. Photo by Oscar Nuñez.

Nicaragua has a sizeable population group that receives health services through private provider organizations contracted by the Nicaraguan Social Security Institute to provide services for insured workers and their families. Up until now, these private provider organizations have not participated in the Mother-Baby-Friendly Health Units Initiative.

That changed on March 28, 2008, when the leading private provider organization in Nicaragua, AMOCSA, became the first private sector organization to be officially certified by the Ministry of Health and UNICEF as “mother and baby friendly.” AMOCSA provides comprehensive health services to its 15,000 members in the Department of Chinandega in western Nicaragua.

Ministry of Health and UNICEF evaluators. Photo by Oscar Nuñez.

AMOCSA’s network of three primary health care clinics and one general hospital in the Department of Chinandega were evaluated by a joint Ministry of Health-UNICEF team in a rigorous, three-day process that combined observations, interviews, and record reviews. The result: AMOCSA’s hospital scored an impressive 99% on the evaluation criteria, and its health centers earned a 95%, high marks that earned the ultimate recognition: certification as “Mother and Baby Friendly.”

The road to certification began in May 2006, when AMOCSA’s Board of Directors assumed the challenge of making their services truly “mother and baby friendly.” USAID’s Quality Assurance Project (QAP) had been working with AMOCSA since 2004 in partnership with the Chinandega regional office of the Ministry of Health, to introduce evidence-based standards of care and quality improvement methods to its maternal and child health services. 

QAP’s child health improvement advisor, Dr. Ivonne Gomez, worked intensively with AMOCSA staff to educate personnel at all levels—from administrative clerks to top management—about the importance of early breastfeeding to an infant’s health and how health facilities can have a major role in encouraging and supporting mothers to breastfeed. They conducted an extensive review of AMOCSA’s existing practices that affected breastfeeding and began an intensive program of training and changing processes to comply with the Ten Steps. QAP’s maternal health advisor, Dr. Luis Urbina, worked with AMOCSA’s obstetrics and gynecology department to integrate breastfeeding counseling in prenatal care and ensure that immediate initiation of breastfeeding and rooming-in became a standard part of AMOCSA’s obstetric care.

The most difficult step to achieve was the tenth: linking with breastfeeding support in the community. Here, AMOCSA personnel came up with creative ways to reach out to patients after delivery, including home visits and encouraging mothers to call personnel living in their neighborhood for help with breastfeeding.

AMOCSA staff and breastfeeding committee with HCI’s Dr. Ivonne Gomez (kneeling in front). Photo by Oscar Nuñez.

Once AMOCSA felt it was ready, USAID’s Health Care Improvement Project (the follow-on project to QAP) did a trial run of the evaluation process to identify areas needing further strengthening. Once these were corrected, AMOCSA formally requested that the Ministry of Health organize its certification evaluation.  The evaluation team completed its work and presented the good news to members of AMOCSA’s breastfeeding committee and other staff at the ceremony on February 22, 2008.

UNICEF’s Maternal and Child Health advisor, Dr. Ivette Sandino, believes that the certification of a private provider organization in a country like Nicaragua is breaking new ground for the Initiative. “The participation of the private sector in the Mother-Baby-Friendly Initiative signals the commitment of civil society to supporting women and helps to reinforce in Nicaragua the single message, that breastfeeding is the best food for the infant and is a right of the mother and baby.”  

The staff of AMOCSA is justifiably proud of their accomplishment.  Speaking at the recognition ceremony, Dr. Marcial Rios, Executive Director of AMOCSA, re-affirmed the institution’s commitment to supporting the human right of newborns to breastfeeding and to assuring the right of mother to have correct and evidence-based information on infant feeding.

Based on this ground-breaking engagement of the private sector in the Mother-Baby-Friendly Health Units Initiative, the USAID Health Care Improvement Project and the Ministry of Health hope to convince other private providers in Nicaragua to follow AMOCSA’s lead.

For more information on the USAID Health Care Improvement Project’s work in Nicaragua, contact Dr. Oscar Nuñez at

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The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development
(USAID) under Contract Number GPH-C-00-02-00004-00.