The studies in this section reflect the effects of the Baby Friendly Initiative in supporting feeding and relationship building. For further information on going Baby Friendly, see our accreditation section. For a summary of how Baby Friendly impacts on long term public health outcomes, see our theory of change document on the About Baby Friendly page.
Development and pretesting of “Becoming Breastfeeding Friendly”: Empowering governments for global scaling up of breastfeeding programmes
The Becoming Breastfeeding Friendly research project is a Yale University initiative, designed in conjunction with global breastfeeding experts, including the World Health Organization (WHO), Unicef and the Gates Foundation. It aims to help countries assess their readiness to scale up breastfeeding support, and thus create a country-specific programme to boost and sustain their breastfeeding rates. This article explores how the project is being developed, including the creation of a BBF toolbox to enable countries to assess their breastfeeding scaling up environment, identify gaps, propose policy recommendations, develop a scaling up plan, and track progress.
Hromi-Fiedler, A, dos Santos Buccini, G, Bauermann Gubert, M, et al (2018). Development and pretesting of “Becoming Breastfeeding Friendly”: Empowering governments for global scaling up of breastfeeding programmes. Maternal & Child Nutrition, doi/10.1111/mcn.12659
Enabling children to be a healthy weight – what we need to do better in the first 1,000 days
A new report from First Steps Nutrition Trust identifies key actions needed to protect children from overweight and obesity in the first 1,000 days of life, including requiring services to become Baby Friendly accredited. The report outlines 18 key actions needed to promote a healthy weight in the early years, including increasing investment in universal breastfeeding support, regulating the misleading commercial influence of food and drinks for infants and young children, and offering greater support for families to practise age-appropriate introduction of solids and responsive feeding.
Effect of a baby-friendly workplace support intervention on exclusive breastfeeding in Kenya
This study assessed the effectiveness of a Baby Friendly workplace support intervention on exclusive breastfeeding in Kenya between 2016 and 2018 on an agricultural farm in Kericho County. The intervention targeted pregnant/breastfeeding women residing on the farm and consisted of a variety of workplace support policies and programme interventions, including providing breastfeeding flexi-time and breaks for breastfeeding mothers. The study included 270 and 146 mother-child dyads in the nontreated (preintervention) group and treated (intervention) group, respectively. Overall, The Baby Friendly workplace support intervention promoted exclusive breastfeeding, especially beyond 3 months in this setting.
Kimani-Murage EW, Wilunda C, Macharia TN, Kamande EW, Gatheru PM, Zerfu T, Donfouet HPP, Kiige L, Jabando S, Dinga LA, Samburu B, Lilford R, Griffiths P, Jackson D, Begin F, Moloney G. Effect of a baby-friendly workplace support intervention on exclusive breastfeeding in Kenya. Matern Child Nutr. 2021 Apr 8:e13191. doi: 10.1111/mcn.13191. Epub ahead of print. PMID: 33830636.
Social value of maintaining baby-friendly hospital initiative accreditation in Australia: case study
This study was conducted in the maternity unit of Calvary Public Hospital, Canberra, an Australian BFHI-accredited public hospital. The costs for maintaining BFHI accreditation in a relatively affluent urban population were assessed and interviews were conducted with the hospital’s Director of Maternity Services and the Clinical Midwifery Educator, guided by a structured questionnaire, which examined the cost (financial, time and other resources) and benefits of each of the Ten Steps. The authors applied the Social Return on Investment (SROI) framework, which consists of mapping the stakeholders, identifying and valuing outcomes, establishing impact, calculating the ratio and conducting sensitivity analysis. The ultimate SROI ratio was approximately AU$ 55:1, meaning every AU$1 invested in maintaining BFHI accreditation by this maternal and newborn care facility generated approximately AU$55 of benefit.
Pramono, A., Smith, J., Desborough, J. et al. Social value of maintaining baby-friendly hospital initiative accreditation in Australia: case study. Int J Equity Health 20,22 (2021). https://doi.org/10.1186/s12939-020-01365-3
UNICEF UK Baby Friendly Initiative: Providing, receiving and leading infant feeding care in a hospital maternity setting—A critical ethnography
This research uses a critical ethnographic approach to explore the influence of the national Unicef UK Baby Friendly Initiative (BFI) standards on the culture of one typical maternity service in England, over a period of 8 weeks, across four phases of data collection between 2011 and 2017. A total of 21 staff and 26 service users engaged in moderate-level participant observation and/or guided interviews and conversations. Basic, organising and a final global theme emerged through thematic network analysis, describing the influence of the BFI on providing, receiving and leading infant feeding care in a hospital maternity setting. It is recommended that ongoing infant feeding policy, practice and leadership balance relational and rational approaches for positive infant feeding care and experiences to flourish.
UNICEF UK Baby Friendly Initiative: Providing, receiving and leading infant feeding care in a hospital maternity setting—A critical ethnography. Matern Child Nutr. 2021;e13114. https://doi.org/10.1111/mcn.13114, , , .
Cost-effectiveness analysis of Baby-Friendly Hospital Initiative in promotion of breast-feeding and reduction of late neonatal infant mortality in Brazil
The purpose of this study was to analyse the cost-effectiveness of Baby-Friendly Hospital Initiative (BFHI) in promoting breastfeeding during the first hour of life and reducing late neonatal mortality. The study was carried out in six hospitals in the city of São Paulo (Brazil) (three being Baby-Friendly Hospitals (BFH) and three non-BFH), with a range of mothers with 24 h postpartum, over 18 years old, single fetus and breastfeeding at the time of the interview. Ultimately, it was concluded that the cost-effectiveness of the BFHI in promoting breastfeeding and reducing neonatal mortality rates justifies the investments required for its expansion within the Brazilian health system.
Silva, O., Rea, M., Sarti, F., & Buccini, G. (2020). Cost-effectiveness analysis of Baby-Friendly Hospital Initiative in promotion of breast-feeding and reduction of late neonatal infant mortality in Brazil. Public Health Nutrition, 1-11. doi:10.1017/S1368980020001871
Motivating Change: a grounded theory of how to achieve large-scale, sustained change, co-created with improvement organisations across the UK
This study explored how we can achieve large-scale, sustained improvements and innovations in healthcare organisations. Taking learnings from Unicef UK, NHS Highland, Healthcare Improvement Scotland and the Baby Friendly Gold accredited East Lancashire Hospitals NHS Trust, the authors highlight the importance of giving staff the opportunity to witness effective change and positive outcomes in order to motivate sustained improvement activity. They also show the value of having a flow of trust within organisations that capitalises on positive peer pressure and suppresses infectious negativity.
Breckenridge, J, Gray, N, Toma, M, et al (2019). Motivating Change: a grounded theory of how to achieve large-scale, sustained change, co-created with improvement organisations across the UK. BMJ, doi.org/10.1136/bmjoq-2018-000553
The impact of the UK Baby Friendly Initiative on maternal and infant health outcomes: A mixed‐methods systematic review
This systematic review of the Unicef UK Baby Friendly Initiative includes papers published between 2002 and 2015. The review demonstrates that the Unicef UK Baby Friendly Initiative increases breastfeeding rates up until the age of six weeks and that this is consistent with studies conducted in other resource rich countries.
The review questions the efficacy of the UK Baby Friendly Initiative and its impact on mothers, concluding that Baby Friendly needs to be ‘situationally modified in resource rich settings’. It is important to note that a situational modification was undertaken in the UK in 2012, using some of the papers cited. The UK standards were expanded to include enhanced staff communication skills, responsive feeding, supporting all parents (regardless of feeding method) to build close and loving relationships with their baby and enhanced support for parents who are formula feeding their baby. A global revision of the Baby Friendly Hospital Initiative was also published by the World Health Organization (WHO) in 2018, drawing on the success of the more holistic UK standards.
Fallon, V.M., Harrold, J.A. & Chisholm, A. (2019). The impact of the UK Baby Friendly Initiative on maternal and infant health outcomes: A mixed‐methods systematic review. Maternal and Child Nutrition, doi/abs/10.1111/mcn.12778
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.
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.
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.
Exposure to Baby-Friendly Hospital Practices and Breastfeeding Outcomes of WIC Participants in Maryland
This study aims to compare maternal perceptions about maternity practices in Baby-Friendly Hospitals and non-Baby-Friendly Hospitals and to evaluate the associations between degree of exposure to the Baby-Friendly 10 Steps and breastfeeding practices through the first 6 months. The study also evaluates whether the receipt of specific Steps was associated with breastfeeding practices through 6 months. Findings concluded that maternal perception of Baby-Friendly Step adherence was associated with exclusive breastfeeding
Ducharme-Smith K, Gross SM, Resnik A, et al. Exposure to Baby-Friendly Hospital Practices and Breastfeeding Outcomes of WIC Participants in Maryland. Journal of Human Lactation. February 2021. doi:10.1177/0890334421993771
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.
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.
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.
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.
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.”
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.
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.
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.
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.
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.
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.
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.
- 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
- 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
Related research and further reading
The Lancet: Increasing breastfeeding worldwide could prevent over 800,000 child deaths every year