Research on the Impact of the Baby Friendly Initiative

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The studies in this section reflect the effect of the Baby Friendly Initiative in supporting feeding and relationship building. For further information on going Baby Friendly, see our accreditation section.

The effect of maternity practices on exclusive breastfeeding rates in US hospitals

This study of the impact of Baby Friendly Hospital Initiative maternity practices on exclusive breastfeeding rates in US hospitals found that whilst many individual practices impacted on breastfeeding rates, only a collection of practices could explain the variability in rates between services. The authors argue that the findings support the need for a systematic approach in providing breastfeeding support.

Patterson, J, Keuler, N, and Olson, B, (2018). The effect of maternity practices on exclusive breastfeeding rates in US hospitals. Maternal & Child Nutrition, doi.org/10.1111/mcn.12670

Formula milk supplementation on the postnatal ward: A cross-sectional analytical study

This study investigated the reasons for early breastmilk substitute (BMS) use in two large maternity units in the UK. Researchers found that during 2016, 28% of infants received a BMS supplement prior to discharge from the hospital maternity units with only 10% supplementation being clinically indicated. There was wide variation in BMS initiation rates between different midwives, and specific management factors associated with non-clinically indicated initiation of BMS were the absence of skin-to-skin contact within an hour of delivery and no attendance at an antenatal breastfeeding discussion. The authors suggest that concordance with Unicef Baby Friendly, attention to specific features of the postnatal ward working environment, and targeted support for mothers and midwives may all lead to improved exclusive breastfeeding rates at hospital discharge.

Biggs, K, Hurrell, K, et al, (2018). Formula milk supplementation on the postnatal ward: A cross-sectional analytical study. Nutrients, doi.org/10.3390/nu10050608

Baby-Friendly practices minimize newborn infants’ weight loss

This study explored the impact of Baby-Friendly practices on newborn weight loss and breastfeeding rates. The researchers found that exclusive breastfeeding increased in all ethnic groups after Baby-Friendly practices were put in place, and there was a statistically significant effect of Baby-Friendly designation on weight loss for day 0–2 in exclusively breastfed infants after controlling for birth weight.

Procaccini, D, & Curley, A, (2018). Baby-Friendly practices minimize newborn infants’ weight loss. Breastfeeding Medicine, doi.org/10.1089/bfm.2017.0182

The effect of Baby-friendly status on exclusive breastfeeding in U.S. hospitals

This study of U.S. hospitals found that Baby Friendly hospital designation was positively correlated with exclusive breastfeeding, independent of demographic variables.

Patterson, J, et al (2018), The effect of Baby-friendly status on exclusive breastfeeding in U.S. hospitals, DOI: 10.1111/mcn.12589

The effect of family policies and public health initiatives on breastfeeding initiation among 18 high-income countries: a qualitative comparative analysis research design

This study explored the effects of macro-level factors – welfare state policies and public health initiatives – on breastfeeding initiation among eighteen high-income countries. It found that the most common pathway leading to high breastfeeding initiation was a combination of conditions including a high percentage of women in parliament, a low national cesarean section rate, and either low family spending, high rates of maternity leave, or high rates of women working part-time. The most common pathway leading to low breastfeeding initiation included the necessary condition of low national adherence to the Baby-Friendly Hospital Initiative. The findings highlight the need for action across government, healthcare and community levels in order to increase breastfeeding rates.

Lubold, AM, (2017). The effect of family policies and public health initiatives on breastfeeding initiation among 18 high-income countries: a qualitative comparative analysis research design, International Breastfeeding Journal, https://doi.org/10.1186/s13006-017-0122-0

Room for improvement in breastmilk feeding after very preterm birth in Europe: Results from the EPICE cohort

This European study found a range of factors positively impacted rates of breastmilk feeding at discharge after very preterm birth, including Baby Friendly Hospital Initiative accreditation, mother’s own milk at first enteral feed, first enteral feed within 24 hours after birth and vaginal delivery. The results suggest a high potential for improving breastmilk feeding through policies and support in the NICU. Find out more about the Baby Friendly neonatal standards in the UK, which support neonatal units to enable sick and preterm babies to receive breastmilk and to breastfeed where possible.

Wilson, E, (2017). Room for improvement in breast milk feeding after very preterm birth in Europe: Results from the EPICE cohort, Maternal and Child Nutrition, DOI: 10.1111/mcn.12485

Baby-Friendly Hospital designation has a sustained impact on continued breastfeeding

This Swiss study of 1,326 children found that the average duration of exclusive breastfeeding and any breastfeeding were the longest in babies in hospitals currently accredited as Baby Friendly. Continued breastfeeding was also significantly longer not only in currently accredited hospitals but also in formerly accredited hospitals.

Spaeth, A, et al (2017), Baby-Friendly Hospital designation has a sustained impact on continued breastfeeding. Maternal & Child Nutrition, DOI: 10.1111/mcn.12497

Systematic Review of Evidence for Baby-Friendly Hospital Initiative Step 3 Prenatal Breastfeeding Education

This American review of studies explored the impact prenatal breastfeeding education (Step 3 of the Global Baby Friendly Hospital Initiative) on breastfeeding rates. Findings suggest that prenatal interventions, delivered alone or in combination with intrapartum and/or postpartum components, are effective at increasing breastfeeding initiation, duration, or exclusivity where they combine both education and interpersonal support and where women’s partners or family are involved.

Wouk, K, et al (2016), Systematic Review of Evidence for Baby-Friendly Hospital Initiative Step 3. Journal of Human Lactation, https://doi.org/10.1177/0890334416679618

Empowering women to breastfeed: Does the Baby Friendly Initiative make a difference?

This research around implementing the Baby Friendly Hospital Initiative in Canada has found that a flexible, family-centred approach is most successful. The authors recommend that services look at empowering women to overcome potential barriers to breastfeeding, rather than simply focusing on the end goal of increasing breastfeeding rates. They say that “successful and sustainable implementation of the BFI requires a level of flexibility, emotional engagement, and critical reflection on the part of health‐care workers that may be forsaken in attempts to quickly achieve the BFI outcomes.”

Groleau, D (2016), Empowering women to breastfeed: Does the Baby Friendly Initiative make a difference? Maternal & Child Nutrition, doi: 10.1111/mcn.12370

Impact of the Baby Friendly Hospital Initiative (BFHI) on breastfeeding outcomes in the US

This study found that the BFHI facilitated successful breastfeeding initiation and exclusivity. The limited data available on breastfeeding duration also suggested that breastfeeding duration increases when mothers have better exposure to Baby Friendly practices. Of the Ten Steps to Successful Breastfeeding, steps 3 (prenatal education) and 10 (postnatal breastfeeding support) were found to be the most difficult to implement but have the best potential to impact maternal breastfeeding decisions.

Munn, A, et al (2016). The Impact in the United States of the Baby-Friendly Hospital Initiative on Early Infant Health and Breastfeeding Outcomes. Breastfeeding Medicine, doi:10.1089/bfm.2015.0135.

Impact of the Baby Friendly Hospital Initiative (BFHI) on breastfeeding and child health outcomes

This study reviewed the impact of BFHI implementation on breastfeeding and child health outcomes. Research was conducted in 19 countries across the Americas, Europe, Asia and Africa. It was found that adherence to the BFHI Standards has a positive impact on breastfeeding outcomes: early breastfeeding initiation, exclusive breastfeeding at hospital discharge and breastfeeding duration. Adherence to the Ten Steps was also linked to a significant decrease in the incidence of gastrointestinal infections and atopic eczema at 1 year of age. Follow-up research found a positive impact on children’s IQ and academic performance, as well as an increased likelihood that mothers would breastfeed their subsequent children for at least three months.

Pérez-Escamilla, R, et al (2016). Impact of the Baby Friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review. Maternal & Child Nutrition, DOI: 10.1111/mcn.12294

Baby Friendly community health services: impact on breastfeeding

This study into the effectiveness of implementing the Baby-friendly Initiative (BFI) in community health services in Norway found that women in the intervention group were more likely to breastfeed exclusively compared with those who received routine care. Maternal breastfeeding experience in the two groups did not differ, neither did perceived breastfeeding pressure from staff in the community health services. In conclusion, implementing the BFI in community health services increased rates of exclusive breastfeeding until six months.

Bærug, A, et al (2016). Effectiveness of Baby-friendly community health services on exclusive breastfeeding and maternal satisfaction: a pragmatic trial. Maternal & Child Nutrition, doi: 10.1111/mcn.12273.

Interventions to improve breastfeeding outcomes

This study provided comprehensive evidence of the effect of interventions on early initiation, exclusive, continued and any breastfeeding rates when delivered in five settings: (i) Health systems and services (ii) Home and family environment (iii) Community environment (iv) Work environment (v) Policy environment or a combination of any of above.

Results indicated that intervention delivery in combination of settings seemed to have higher improvements in breastfeeding rates. Greatest improvements in early initiation of breastfeeding, exclusive breastfeeding and continued breastfeeding rates, were seen when counselling or education were provided concurrently in home and community, health systems and community, health systems and home settings, respectively. Baby Friendly Hospital support at health system was the most effective intervention to improve rates of any breastfeeding.

Sinha, B. et al (2015). Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis. Acta Paediatrica, Special Issue: Impact of Breastfeeding on Maternal and Child Health. Volume 104, Issue Supplement S467, pages 114-134.

Factors associated with exclusive breastfeeding at hospital discharge

This study of 427 mothers in Australia found that found that hospital practices are strong predictors of exclusive breastfeeding. The researchers suggest that greater emphasis on Baby-Friendly hospital practices in the early postpartum period may help the establishment of exclusive breastfeeding.

Cox et al (2014), Factors Associated with Exclusive Breastfeeding at Hospital Discharge in Rural Western Australia. Journal of Human Lactation, doi: 10.1177/0890334414547274

Impact of Baby Friendly accreditation on breastfeeding rates, cognitive outcomes and maternal mental health

Using data from the UK Millennium Cohort Study, these researchers found that women giving birth in hospitals that participated in the Baby Friendly Initiative (BFI) were up to 15 percentage points more likely to initiate breastfeeding and between 8 and 9 percentage points more likely to breastfeed exclusively at 4 and 8 weeks than comparable mothers giving birth in non-participating hospitals. Mothers from low income families, and with low levels of education, were more responsive to the BFI programme than highly educated mothers in more affluent families.

They then compared the outcomes of children who were breastfed as a result of the BFI program with those of otherwise similar non-breastfed children. They found significant effects of breastfeeding on cognitive outcomes throughout childhood, and in particular between ages 3 and 7. In contrast to the previous literature, researchers found no statistically significant impact of breastfeeding on a number of health outcomes, but saw an improvement in child emotional development and maternal mental health.

Del Bono E, Rabe B. Breastfeeding and child cognitive outcomes: Evidence from a hospital-based breastfeeding support policy. ISER Working Paper Series: 2012-29

Impact of continuing breastfeeding education of nurses and midwives

This study found that continuing breastfeeding education for nurses and midwives improves their knowledge, skills, practices, and attitudes, and it increases maternal perception of support. Breastfeeding education for health professionals also plays an important role in improving breastfeeding outcomes.

A Critical Review of the Impact of Continuing Breastfeeding Education Provided to Nurses and Midwives. Kathryn Nicole Ward and Jennifer P. Byrne. J Hum Lact. 2011; 27(4): p. 381-393.

Implementing Baby Friendly in Australia: midwives’ perceptions

These focus groups of midwives in Australia found that participants considered BFHI implementation to be a high priority, an essential and innovative set of practices that would have positive benefits for babies and mothers both locally and globally as well as for health professionals. It was considered achievable but would take commitment and hard work to overcome the numerous challenges including a number of organisational constraints. It was also recognised that without a lead person/group, implementation would be very difficult. There were, however, differing interpretations of what was required to attain BFHI accreditation with the potential that misinterpretation could hinder implementation. The researchers conclude that, in this area of Australia, despite strong support for BFHI, the principles of this global strategy are interpreted differently by health professionals and further education and accurate information is required.

Schmied V, Gribble K, Sheehan A, et al (2011) Ten Steps or climbing a mountain: A study of Australian health professionals’ perceptions of implementing the Baby Friendly Health Initiative to protect, promote and support breastfeeding. BMC Health Services Research 2011, 11:208doi:10.1186/1472-6963-11-208

The effect of health visitors on breastfeeding in Glasgow

Research from Glasgow suggests that babies who are breastfeeding at the first routine health visitor contact at 10 days are twice as likely to be breastfeeding at the second routine health visitor contact at six weeks if the health visitor had received training in breastfeeding in the previous two years. The study is of particular interest as it describes a real life setting where health visitors are in their normal working environment, not everybody is well trained and not everybody has a positive attitude to breastfeeding.

The authors suggest that the Unicef UK Baby Friendly Initiative breastfeeding course may be a suitable training course for health visitors and conclude that this important finding should be used to encourage health service managers to ensure that health professionals who come into contact with breastfeeding mothers receive adequate training.

Tappin D, Britten J, Broadfoot M, McInnes R. The effect of health visitors on breastfeeding in Glasgow. International Breastfeeding Journal 2006; 1:11

Baby Friendly accreditation increases breastfeeding rates

Research has found that UK mothers delivering in Baby Friendly accredited hospitals are 10% more likely to initiate breastfeeding than those who deliver in non-accredited units or units with a Certificate of Commitment (1). The study, part of the Millennium Cohort Study of 18,819 children, concurs with routinely collected data from Scotland which found that Baby Friendly accreditation increases breastfeeding rates by 8% at 7 days after delivery (2). These findings confirm that the UNICEF Baby Friendly Initiative is the first ever national intervention to have a positive effect on breastfeeding rates in the UK. However, the study found that Baby Friendly hospital accreditation is not associated with an increase in breastfeeding at one month of age and the authors call for further interventions to help mothers sustain breastfeeding.

  1. Bartington S, Griffiths L, Tate A, Dezateux C and the Millennium Cohort Study Child Health Group (2006). Are breastfeeding rates higher among mothers delivering in Baby Friendly accredited maternity units in the UK? International Journal of Epidemiology. doi:10.1093/ije/dyl155
  2. Broadfoot M, Britten J, Tappin DM and MackKenzie JM (2005). The Baby Friendly Initiative and breastfeeding rates in Scotland. Arch Dis Child Fetal Neonatal Ed. 2005;90:114-116