Baby Friendly Hospital Initiative

Background

Health agencies recommend exclusive breastfeeding for the first six months of life. Breastfed babies have lower risks of gastroenteritis, asthma, eczema, and respiratory and ear infections.

Adults who were breastfed may have reduced risks of obesity and high blood pressure. Mothers who do not breastface face increased risks of heart disease, hypertension, diabetes, high cholesterol, breast cancer, ovarian cancer, and hip fractures. The BFHI aims to increase exclusive breastfeeding worldwide, which the WHO estimates could help avoid over a million child deaths each year and many premature maternal deaths.

Criteria

The 2018 criteria for Baby Friendly accreditation include critical management procedures: full compliance with the International Code of Marketing of Breast-milk Substitutes; a written infant feeding policy communicated to staff and parents; ongoing monitoring and data-management systems; and ensuring staff have sufficient knowledge and skills to support breastfeeding. Key clinical practices require discussing breastfeeding with pregnant women and their families; facilitating immediate skin-to-skin contact and supporting early initiation of breastfeeding; supporting mothers to maintain breastfeeding and manage difficulties; not providing breastfed newborns any food or fluids other than breast milk unless medically indicated; enabling rooming-in 24 hours a day; supporting mothers to recognize infant feeding cues; counseling on the use and risks of feeding bottles, teats, and pacifiers; and coordinating discharge so parents have access to ongoing support.

The program restricts free formula or infant care aids from formula companies and recommends that medically needed formula be given in a small cup or spoon rather than a bottle.

Regional schemes

In Canada, Quebec and New Brunswick have mandated BFHI implementation. All public health units in Ontario have been required to work toward BFI designation since 2011, and in 2012 the Ministry of Health and Long Term Care added BFI status to progress indicators for Public Health Units. As of 2008, 18 health care facilities had been designated Baby-Friendly across Canada, with B.C. Women's Hospital and Health Centre being the largest hospital in the country to receive the designation.

China has more than 6,000 Baby-Friendly Hospitals; exclusive breastfeeding in rural areas rose from 29% in 1992 to 68% in 1994, and in urban areas from 10% to 48%. In Cuba, 49 of 56 hospitals and maternity facilities are designated, and exclusive breastfeeding at four months almost tripled from 25% in 1990 to 72% in 1996. In Hong Kong, several hospitals have shown interest, but only Queen Elizabeth Hospital has advanced past the Award of Level 2 Participation.

The BFHI started in Ireland in 1998 under the Irish Health Promoting Hospitals Network and became an independent registered charity in mid-2016, offering a participation level and a designation level with external assessment. Sweden is considered the global leader: four years after the programme was introduced in 1993, all 65 maternity centres had been designated.

Criticism and responses to criticism

A paper published in October 2016 questioned whether full compliance with the ten steps might inadvertently promote hazardous practices or counterproductive outcomes, including increased risk of sudden unexpected postnatal collapse, rigidly-enforced rooming-in leading to exhausted or heavily medicated mothers caring for newborns, and an unnecessary ban on pacifier use. A 2016 systematic review found that following the Ten Steps had a positive impact on short, medium, and long-term breastfeeding outcomes, but noted that all US evidence came from observational studies of very low or low quality, and the long-term impact on breastfeeding outcomes remained unclear.

A 2019 study in the Journal of Pediatrics showed that increased BFHI implementation was temporally associated with a decrease in infant deaths in the first six days after birth, dispelling concerns about increased infant death from asphyxiation; the authors did not discuss other potential harms such as increased neonate hospital admission due to dehydration or poor maternal mental health outcomes.

Did You Know?

• Special formula for premature babies is recommended by the WHO only if breast-milk is medically not an option.
• The WHO advocates the importance of a baby being close to its mother whenever possible even if the mother does not breastfeed.