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; Jolles 2021):

  • 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 (Oren 2020; Shan 2018). 


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