Baby-friendly hospitals

What should I look for in a hospital?

Some hospitals are certified as “baby-friendly.” That means they have met the standards of an international program created to help hospitals provide the best care possible for mothers and babies. They will support the mother’s decision to breastfeed or to infant formula-feed and are guided by a list of standards. Baby-friendly hospitals have been shown to increase breastfeeding rates and prevent illness. Being baby-friendly ensures a level of care, but hospitals without that status can also provide excellent breastfeeding support.

A) Describing the Baby-friendly Hospital Initiative

The Baby-Friendly Hospital Initiative (BFHI) is a global program created in 1990 by the World Health Organization and the United Nations Children's Fund (UNICEF) to help hospitals provide the best possible care related to baby feeding and mother-baby bonding (WHO/UNICEF 1990).

Baby-friendly is now the standard of care (Pound 2012).

Becoming a certified baby-friendly hospital means (WHO 2009):

  • Meeting all baby-friendly criteria.
  • Obtaining certification from a national certifying committee.
  • Undergoing regular re-certification.

Being a certified baby-friendly hospital means that every staff member has the required breastfeeding knowledge. This includes anyone working in the hospital: directors, cleaning staff, health-care providers, and learners.

Hospital staff in a certified baby-friendly hospital support the mother’s decision to breastfeed or to infant formula-feed. If she decides to breastfeed, trained staff will help her. They will not give infant formula to a baby unless it’s medically necessary or the mother asks for it. Nor do they separate mothers and babies unless medically necessary. 

Baby-friendly guidelines also exist for neonatal intensive care units (NICUs) (Nyqvist e2013).

Some of the existing guidelines may also be modified as new research emerges (Gomez-Pomar 2018).

B) The Ten Steps

Baby-friendly hospitals are guided by the “Ten Steps” (WHO 2018):

Critical Management Procedures:

1a. Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions.

1b. Have a written infant feeding policy that is routinely communicated to staff and parents.

1c. Establish ongoing monitoring and data-management systems.

2. Ensure that staff have sufficient knowledge, competence, and skills to support breastfeeding.

Key clinical practices:

  1. Discuss the importance and management of breastfeeding with pregnant women and their families.
  2. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.
  3. Support mothers to initiate and maintain breastfeeding and manage common difficulties.
  4. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.
  5. Enable mothers and their infants to remain together and to practise rooming-in 24 hours a day.
  6. Support mothers to recognize and respond to their infants’ cues for feeding.
  7. Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.
  8. Coordinate discharge so that parents and their infants have timely access to ongoing support and care.

The process of becoming a baby-friendly hospital is a hospital-wide undertaking. While the Ten Steps provide clear expectations, implementing them is not as straightforward as it seems. For example, saying that mothers and babies should not be separated means:

  • Babies are kept skin-to-skin immediately after birth, whether it was vaginal or by Caesarean section.
  • All examinations and blood tests are done while the baby is with the mother.
  • Babies are not kept in nurseries overnight to “help the mother sleep.”

C) Benefits of the BFHI

Babies born in baby-friendly hospitals tend to have greater breastfeeding success with higher rates of (Fair 2021; Silva 2020):

  • Starting to breastfeed.
  • Starting to breastfeed within one hour of birth.
  • Exclusive breastfeeding.
  • Breastfeeding duration.

Babies are given fewer unnecessary milk supplements (Marinelli 2019)

They have better health outcomes including:

  • Less weight loss after delivery whether breast- or infant formula-fed (Procaccini 2018)
  • Less jaundice (Hudson 2020)
  • Fewer stomach infections (Martens 2012).
  • Less eczema (atopic dermatitis) as teenagers (Flohr 2018).
  • Higher verbal IQ scores (Kramer 2001; Martens 2012; Yang 2018).
  • Lower rates of death (sudden unexpected infant death [SUID], infection, or other causes) (Bartick 2019; Silva 2020).

D) Finding a baby-friendly hospital

The majority of hospitals are not baby-friendly. The World Health Organization reviewed information from 168 countries and reported that about 10% of babies in those countries were born in baby-friendly hospitals (WHO 2017). The rate varies widely among countries: 35% of European babies were born in such hospitals, but less than 5% of babies in Africa and Southeast Asia. Only 43% of the countries reported that at least some of the Ten Steps had been used in developing national quality standards for maternal, newborn, and child healthcare.

While the trends are promising, in the U.S.A. in 2015, 72% of hospitals still continued to accept free infant formula and less than 20% limited pacifier use or non-breast milk feeds to those that were medically necessary, or helped mothers start breastfeeding within one hour of delivery (Nelson 2019).

Ask about your hospital’s baby-friendly status and programs. Being baby-friendly ensures a level of care, but hospitals without that status can also provide excellent breastfeeding support (Barrera 2019; Phillip 2010).

No matter which hospital you use, always ensure that your newborn takes in enough milk and is not underfed. Problems can happen in any hospital, even one that is baby-friendly (Bass 2016). For example, eliminating routine infant formula supplements can unmask breastfeeding problems that without proper training, may not be properly fixed or may even be missed (Shan 2018). 

References

Barrera CM, Beauregard JL, Nelson JM, et al. Association of Maternity Care Practices and Policies with In-Hospital Exclusive Breastfeeding in the United States. Breastfeed Med. 2019 May;14(4):243-248

Bartick M, Boisvert ME, Philipp BL, et al. Trends in Breastfeeding Interventions, Skin-to-Skin Care, and Sudden Infant Death in the First 6 Days after Birth. J Pediatr. 2019 Nov 14;S0022-3476(19)31305-8
 
Bass JL, Gartley T, Kleinman R. Unintended Consequences of Current Breastfeeding Initiatives. JAMA Pediatr. 2016 Oct 1;170(10):923-924

Fair FJ, Morrison A, Soltani H. The impact of Baby Friendly Initiative accreditation: An overview of systematic reviews. Matern Child Nutr. 2021 Jun 1:e13216
 
Flohr C, Henderson AJ, Kramer MS, et al. Effect of an Intervention to Promote Breastfeeding on Asthma, Lung Function, and Atopic Eczema at Age 16 Years: Follow-up of the PROBIT Randomized Trial. JAMA Pediatr. 2018 Jan 2;172(1):e174064
 
Gomez-Pomar E, Blubaugh R. The Baby Friendly Hospital Initiative and the ten steps for successful breastfeeding. a critical review of the literature. J Perinatol. 2018 Jun;38(6):623-632

Kramer MS, Chalmers B, Hodnett ED, et al. Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus. JAMA. 2001;285(4):413-420 

Marinelli A, Del Prete V, Finale E, et al. Breastfeeding with and without the WHO/UNICEF baby-friendly hospital initiative: A cross-sectional survey. Medicine (Baltimore). 2019;98(44):e17737
 
Martens PJ. What do Kramer's Baby-Friendly Hospital Initiative PROBIT studies tell us? A review of a decade of research. J Hum Lact. 2012 Aug;28(3):335-42

Nelson JM, Grossniklaus DA. Trends in Hospital Breastfeeding Policies in the United States from 2009-2015: Results from the Maternity Practices in Infant Nutrition and Care Survey. Breastfeed Med. 2019 Apr;14(3):165-171
 
Nyqvist KH, Häggkvist AP, Hansen MN, et al.; Baby-Friendly Hospital Initiative Expert Group. Expansion of the baby-friendly hospital initiative ten steps to successful breastfeeding into neonatal intensive care: expert group recommendations. J Hum Lact. 2013 Aug;29(3):300-9
 
Philipp BL; Academy of Breastfeeding Medicine Protocol Committee. ABM Clinical Protocol #7: Model Breastfeeding Policy (Revision 2010). Breastfeed Med. 2010 Aug;5(4):173-7
 
Pound C, SL Unger; Canadian Paediatric Society. The Canadian Pediatric Society Position Statement. The Baby-Friendly Initiative: Protecting, promoting and supporting breastfeeding. Paediatr Child Health 2012;17(6):317-21

Procaccini D, Curley ALC, Goldman M. Baby-Friendly Practices Minimize Newborn Infants Weight Loss. Breastfeed Med. 2018 Feb 28
 
Shan KH, Wang TM, Lin MC. Association between rooming-in policy and neonatal hyperbilirubinemia. Pediatr Neonatol. 2018 Jun 12

Silva OLO, Rea MF, Sarti FM, et al. Cost-effectiveness analysis of Baby-Friendly Hospital Initiative in promotion of breast-feeding and reduction of late neonatal infant mortality in Brazil. Public Health Nutr. 2020 Jul 20:1-11 

World Health Organization (WHO). National Implementation of the Baby-friendly Hospital Initiative, 2017. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO
 
World Health Organization (WHO). Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care. Geneva: World Health Organization; 2009
 
World Health Organization and UNICEF (WHO/UNICEF). Protecting, promoting and supporting breastfeeding: the special role of maternity services. A joint WHO/UNICEF statement. A joint WHO/UNICEF statement. A joint WHO/UNICEF statement. Int J Gynaecol Obstet. 1990;31(Suppl 1):171-183.
 
World Health Organization (WHO). Implementation guidance: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services – the revised Baby-friendly Hospital Initiative. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO
 
Yang S, Martin RM, Oken E, et al. Breastfeeding during infancy and neurocognitive function in adolescence: 16-year follow-up of the PROBIT cluster-randomized trial. PLoS Med. 2018 Apr 20;15(4):e1002554