Baby Friendly Hospital Initiative

The Baby Friendly Hospital Initiative (BFHI), also known as Baby Friendly Initiative (BFI), is a worldwide programme of the World Health Organization and UNICEF, launched in 1992 in India [1][2] following the adoption of the Innocenti Declaration on breastfeeding promotion in 1990.[3] The initiative is a global effort for improving the role of maternity services to enable mothers to breastfeed babies for the best start in life. It aims at improving the care of pregnant women, mothers and newborns at health facilities that provide maternity services for protecting, promoting and supporting breastfeeding, in accordance with the International Code of Marketing of Breastmilk Substitutes.[4]


UNICEF, the World Health Organization, and many national government health agencies recommend that babies are breastfed exclusively for their first six months of life. Studies have shown that breastfed babies are less likely to suffer from serious illnesses, including gastroenteritis, asthma, eczema, and respiratory and ear infections.[5][6][7][8] Adults who were breastfed as babies may be less likely to develop risk factors for heart disease such as obesity and high blood pressure. There are benefits for mothers too: women who don't breastfeed have increased risk of developing heart disease, hypertension, diabetes, high cholesterol, breast cancer, ovarian cancer and hip fractures in later life.[9][10][11] The BFHI aims to increase the numbers of babies who are exclusively breastfed worldwide, a goal which the WHO estimates could contribute to avoiding over a million child deaths each year, and potentially many premature maternal deaths as well.[12][13][14]


The criteria for a hospital's Baby Friendly accreditation (2018) include:

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

3. Discuss the importance and management of breastfeeding with pregnant women and their families.

4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.

5. Support mothers to initiate and maintain breastfeeding and manage common difficulties.

6. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.

7. Enable mothers and their infants to remain together and to practise rooming-in 24 hours a day.

8. Support mothers to recognize and respond to their infants’ cues for feeding.

9. Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.

10. Coordinate discharge so that parents and their infants have timely access to ongoing support and care.

The program also restricts use by the hospital of free formula or other infant care aids provided by formula companies and recommends that when formula is medically needed, it should be given in a small cup or spoon, rather than a bottle and should only be used to supplement breastfeeding.

Since the program's inception, approximately 15,000 facilities in more than 152 countries have been inspected and accredited as "Baby-Friendly."[1][2]

Recommended alternativesEdit

The World Health Organization recommends that if a mother is unable to breastfeed, chooses not to breastfeed, or if her baby (often premature) shows signs that it isn't getting enough breast-milk, a healthy wet nurse or milk from a donor is a healthy alternative to formula.[15] A special formula is manufactured for premature babies, although the World Health Organization recommends it only if breast-milk is medically not an option such as if a premature baby has to be fed formula through a tube to maintain a healthy weight.[15] The World Health Organization advocates the importance of a baby being close to its mother whenever possible even if the mother does not breastfeed.[16]

Regional schemesEdit


In Canada, the provinces of Quebec and New Brunswick have mandated the implementation of the BFHI. All public health units in Ontario have been required to work towards having BFI designation since 2011.[17] In 2012, the Ministry of Health and Long Term Care in Ontario added BFI status to their progress indicators for Public Health Units thus requiring all Public Health Units in Ontario to begin implementation of BFI.[18] Other provinces and territories are implementing strategies at regional and local levels.[19] As of 2008, 18 health care facilities (9 hospitals & birthing centres and 9 community health services) had been designated "Baby-Friendly" across the country.[20] The B.C. Women's Hospital and Health Centre has been recognized as a breast-feeding and “baby-friendly” hospital by the World Health Organization (WHO) and UNICEF since 2008. It is the largest hospital in Canada to receive the designation.[21]


China, now has more than 6,000 Baby-Friendly Hospitals, exclusive breastfeeding in rural areas rose from 29 per cent in 1992 to 68 per cent in 1994; in urban areas, the increase was from 10 per cent to 48 per cent.[1]


In Cuba, 49 of the country's 56 hospitals and maternity facilities have been designated as "baby-friendly". In the six years following the initiation of the BFHI program, the rate of exclusive breastfeeding at four months almost tripled - from 25 per cent in 1990 to 72 per cent in 1996.[1]

Hong KongEdit

In Hong Kong several hospitals have shown interest in being designated Baby Friendly. However, only Queen Elizabeth Hospital has advanced past the Award of Level 2 Participation stage and is well on its way to receiving BFHI accreditation.[22]


The BFHI started in Ireland in 1998 under the auspices of the Irish Health Promoting Hospitals Network (a WHO programme). The BFHI in Ireland became an independent registered charity in mid-2016 and changed their name to Baby Friendly Health Initiative. They offer two levels - a participation or membership level in which maternity facilities are encouraged to implement the standards and network with other maternity facilities but with no external assessment process, and the designation level where there is external assessment and on-going monitoring to ensure the standards are met and sustained.[23]


Sweden is considered the global leader in terms of BFHI implementation: four years after the programme was introduced in 1993, all of the then 65 maternity centres in the country had been designated "baby-friendly".[24]


In 2014 78.60% of babies were born in BFHI hospitals. Between 2001 and 2013, the increase in certified hospitals was from 38 to 176.[25]

United KingdomEdit

The UNICEF UK Baby Friendly Initiative was launched in the United Kingdom in 1995.[26] The Initiative works with the National Health Service (NHS) to ensure a high standard of care for pregnant women and breastfeeding mothers and babies in hospitals and community health settings. The Baby Friendly Initiative accredits health-care facilities that adopt internationally recognised best practice standards for breastfeeding.[27] During each stage of accreditation, the Initiative provides support as facilities implement standards relating to policies and procedures, staff education, effective auditing, educating pregnant women and mothers, and other relevant areas.

In 1998, its principles were extended to cover the work of community health-care services with the Seven Point Plan for the Promotion, Protection and Support of Breastfeeding in Community Health Care Settings.[27] In 2005, it introduced an accreditation programme for university departments responsible for midwifery, health visitor and public health nurse education. This ensures that newly qualified midwives and health visitors are equipped with the basic knowledge and skills they need to support breastfeeding effectively. The program's emphasis on applying the standards in post-natal and education settings makes it unique amongst the various Baby Friendly programmes in other countries.[citation needed]

There are now 52 Baby Friendly-accredited maternity hospitals in the UK and ten accredited community health-care providers.[citation needed] It has been estimated that if all babies were breastfed, over £35m would be saved by the NHS in England and Wales each year in treating gastroenteritis alone.[28] Despite this, breastfeeding rates in the UK are amongst the lowest in Europe: 78 per cent of babies born in the UK are breastfed at birth, falling to 63 per cent at one week. Only one in five babies still receives breastmilk at six months.[29] In 2009, the Department of Health awarded a total of £4 million to 40 primary care trusts in areas with low rates of breastfeeding to support them in seeking Baby Friendly accreditation.[citation needed]

By the end of 2013 the success of the initiative in Scotland meant that 90% of Scottish mothers now give birth in a UNICEF-accredited Baby Friendly hospital. This compares with 30% of mothers in England, 58% for Wales and 57% in Northern Ireland.[30]

United StatesEdit

The first hospitals verified as Baby-Friendly in the USA were on the Pacific Coast. The first US hospital to receive this designation was Evergreen Hospital Medical Center, in Kirkland, Washington, which was certified in September 1996.[31] All of these early adopters were able to achieve 100% breastfeeding initiation rates.[32] In New York City, the Harlem Hospital Center was the first hospital to receive the "Baby Friendly" certification granted by Baby-Friendly USA for the city in 2008.[33] In 2011, New York University Langone Medical Center became the second hospital to receive the Baby-Friendly Hospital designation in New York City.[34]

As of May 2, 2018, the United States only had 512 hospitals that hold the Baby-Friendly designation. This translates to 24.57% of annual births occurring in a Baby-Friendly hospital.[35] Mothers in the United States face prejudice regarding breastfeeding their children. The US Surgeon General reported in 2001 that 57% of U.S. adults believe that a woman should not be allowed to breastfeed in public places and not all states protect women from being charged with public indecency for breastfeeding in public.[36] A study conducted by Bartick and Reinhold, determined that $10.5 billion US dollars could be saved if 80% of families in the United States were able to meet current recommendations for exclusive breastfeeding for the first 6 months of life, that cost-savings jumps to $13 billion saved if 90% of families comply.[37] Lower income households are often eligible for Medicaid and WIC, by breastfeeding, these agencies have been estimated to save $478 during the first six months of the infant's life for each infant.[38]

Studies have also shown a positive correlation of breastfeeding with increased professional education of care providers.[39] 86% of Americans rely on professional healthcare providers like doctors, midwives, and nurses for medical advice and recommendations.[40] Classes are then offered in group and individual settings as "low-intensity intervention" directed by trained medical professionals.[41] Research conducted at large healthcare institutions in Massachusetts has demonstrated a statistically significant increase in breastfeeding rates for mothers who participate in breastfeeding and lactation training.[42] Using a high-fidelity (realistic) breast model for teaching health professionals to assist families with breastfeeding could lead to larger improvements in breastfeeding rates.[43]

Criticism and responses to criticismEdit

One group of authors expressed concerns in a paper published in October 2016. It questioned whether full compliance with the ten steps of the initiative might inadvertently lead to the promotion of potentially hazardous practices and/or counterproductive outcomes. Specific concerns described in this paper included increased risk of Sudden Unexpected Postnatal Collapse, rigidly-enforced rooming-in practices leading to exhausted or heavily medicated mothers caring for newborns, and an unnecessary ban on pacifier use.[44]

A 2016 systemic review examined the impact of BFHI implementation on breastfeeding and child health outcomes worldwide and in the United States. The authors found that following the BFHI Ten Steps had a positive impact on short, medium, and long-term breastfeeding outcomes. Looking at 58 studies, the review found that community support was the key to long-term sustainability of breastfeeding that was initiated in the BFHI hospital setting.[45]

A study published in the Journal of Pediatrics in 2019 showed that increased rates of implementation of the BFHI were associated with a decrease in the rate of infant deaths in the first six days after birth. The authors said that their findings dispelled the suggestion that hospital-based breastfeeding initiatives might increase infant death.[46]


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