Malnutrition is responsible directly or indirectly, for about one third of deaths among children under five. Nutrition and nurturing during the first years of life are crucial for life-long health and wellbeing. Exclusive breastfeeding is known to benefit mother, child, environment, and to be cost- effective. The Baby-Friendly Hospital Initiative (BFHI) is a global effort that aims to implement practices that protect, promote and support breastfeeding. This paper will discuss the program’s history and purpose, and evaluate its success globally and by comparison in two states. Although the BFHI has been successful, barriers to breastfeeding still exist. Additional cost effective changes to promote breastfeeding must be explored and advocacy is encouraged.
Keywords: malnutrition, breastfeeding, practices, baby-friendly, advocacy
The Baby Friendly Hospital Initiative: Breastfeeding for Life The experience of breastfeeding is essential and special for many reasons. It allows for maternal infant bonding, provides cost savings, and is the perfect nutrition for the infant or young child. It provides health benefits to the baby as well as the mother. Breast milk is easy to digest and contains disease fighting antibodies which help protect infants from bacterial and viral illness. Children, who are breastfed, demonstrate a decreased incidence of SIDS, obesity, diabetes asthma, and otitis media, and experience enhanced development and intelligence (Smithers &McIntyre, 2010). Mothers who breast feed have been shown to have a lower risk of health problems including breast cancer, ovarian cancer, and type II diabetes (Galston, 2008). These are just a few of the many known health benefits to child and mother. Environmentally, breastfeeding is good practice as there are no bottles or nipples which need a method of disposal, formula to be rendered, or supplies to be cleaned.
The World Health Organization (2009) recommends that infants start breastfeeding within one hour of life, and are exclusively breastfed for six months. Timely introduction of adequate, safe and properly fed complementary foods are encouraged, while the baby continues to breastfeed for up to two years of age or beyond. Exclusive breastfeeding is defined as no other food and drink, including water, except breast milk, for the first 6 months of life. The policy allows the infant to receive rehydration salts, drops, and syrups (vitamins, minerals and medication) if needed. Breastfeeding is a learned skill, and often requires practice. For some women, the learning stages can be frustrating and uncomfortable. This frustration can be compounded if the baby is born premature; the mother has health issues, or needs a cesarean section.
Aversion to breastfeeding also increases when the mother knows she must return to work, and will need to manage the issue of breast pumping. An additional option would be to have the baby nearby. Employers are commonly not supportive of the process, which can make continued breastfeeding a difficult concept for a new mother to comprehend. However, under the new health care reform law, employers are required to provide a private space and breaks for pumping (Rubin, 2010). In underdeveloped and poor areas, supportive factors such as education and training are also in short supply. The Baby- Friendly Hospital Initiative (BFHI) is a global effort which targets these issues through awareness and education in the hospital setting.
Health Policy and Organizational Support
BFHI is a program of the World Health Organization (WHO) and The United Nations International Children’s Emergency Fund (UNICEF). It was launched in 1991 in response to the Innocenti Declaration of 1990. At least 30 governments signed on to this declaration, a document that set ambitious standards for national support to breastfeeding (UNICEF, 2005). The initiative is a global effort for improving the role of maternity services across the world to enable mothers to breastfeed babies. It aims to improve the care of pregnant women, mothers, and newborns at hospitals that provide maternity services. The hope is to protect, promote, and support breastfeeding within each facility. The guidelines and materials were revised in 1995, and updated and expanded to promote integrated care. These updated materials reflect new research, support mothers who are not breastfeeding, provide modules on HIV and infant feeding, promote mother- friendly care, and give more specialized guidelines for monitoring and reassessment (World Health Organization, 2009).
The initiative provides the guidelines for country and hospital implementation of the program, and sets the global criteria for the BFHI. The global criteria serve as the standard for measuring adherence to the Ten Steps for Successful Breastfeeding. Since it was launched, the BFHI has grown, with many countries around the world implementing the initiative. As of 2005, nearly 20,000 hospitals in 150 countries had become “Baby- Friendly” (UNICEF, 2005). Currently, in the United States, there are about 105 Baby- Friendly Hospitals (Baby- Friendly USA, 2010). The BFHI has shown measureable and proven impact, increasing the likelihood of babies being exclusively breastfed for the first six months (World Health Organization, 2009). The criteria for accreditation are the implementation of the Ten Steps for Successful Breastfeeding within the facility. The steps are clearly outlined. The hospital must have a written breastfeeding policy, and train all health care staff in the skills necessary to implement the policy. Pregnant mothers are to be informed about the benefits and management of breastfeeding.
Rooming in should be practiced, and breastfeeding should be initiated within one half-hour of birth. Mothers should be taught to breastfeed, even in a situation where they will be separated from the child. Unless medically indicated, infants should be given no food or drink other than breast milk, including sips of water. Pacifiers are not to be given to an infant who is breastfed. Breastfeeding on demand is to be taught and encouraged. Finally, breastfeeding support groups should be fostered, and mothers should be referred to the groups upon discharge (World Health Organization, 2009). These ten practices are considered by the BFHI as the steps necessary to help support successful breastfeeding.
The BFHI has been shown to be lifesaving as well as cost effective. More than one million infants die worldwide every year. Many of these deaths could be prevented by successful breastfeeding. Other children are put at risk unnecessarily because they are given other foods too early. In addition, 10 million die annually from preventable diseases like diarrhea and respiratory infections (Black et al, 2008). Millions more live in poor health, contract preventable diseases, and fight against malnutrition. Breastfeeding is widely understood to prevent diarrhea and decrease infection. Black et.al (2008), noted that suboptimal breastfeeding is estimated to be responsible for 1.4 million child deaths and 44 million global childhood Disability Adjusted Life Years (DALYS). This is a representation of 10% of all childhood DALYS. The magnitude of death and disease is greater in undeveloped countries, but many infants in the United States also suffer from the ill effects of suboptimal feeding practices.
A decreased risk of diarrhea, and respiratory and ear infections are some of the many benefits to breastfeeding infants in industrialized countries. In the United States, these benefits could translate into millions of dollars in savings to our health care system through decreased hospitalizations and clinic visits. Baby- Friendly USA states that for diarrhea alone, approximately 200,000 US children are hospitalized each year resulting in a cost of more than half a billion dollars. The organization also points out that the incidence of prolonged episodes of otitis media is 80 percent lower in breastfed as compared to non-breastfed infants, and that cost savings to the health care system would be enormous if more infants were breastfed with prolonged duration. Prolonged breastfeeding is widely attributed to health benefits to the mother and baby.
Benefits to the baby include decreased risk for allergies, SIDS, stomach virus, diarrhea, lower respiratory infection, ear infection, meningitis and lower incidence of obesity and diabetes later in life. Benefits to the mother include a decreased risk for breast and ovarian cancer, and less incidence of postpartum depression. It is evident that these factors would have an impact on Health Adjusted Life Expectancy (HALE) worldwide. Consider that obesity alone has been shown to have a dramatic effect on life expectancy. Whitlock et.al (2009) noted that Body Mass Index (BMI) was noted to be a strong predictor of mortality. Those with moderate obesity (BMI 30-35 Kg/m2) demonstrated a reduction of life expectancy by three years. Those with severe obesity (BMI 40-50 Kg/m2) showed an 8-10 year reduction in life expectancy. Data collection regarding the specific impact of the BFHI is well underway. Researchers in Texas conducted an economic assessment evaluating the cost of implementing the BFHI in U.S. acute care hospital settings.
The study concluded that the process is relatively cost- neutral (DelliFraine et al., 2011). A survey of the nation’s first 29 Baby-Friendly hospitals found that the breastfeeding initiation rate at the Baby-Friendly hospitals averaged 83 percent in 2001, when the national average was 69.5 percent, and that the mean exclusive breastfeeding rate at Baby-Friendly hospitals was 78.4 percent compared to 46.3 percent nationwide (Merewood, Mehta, Chamberlain, Phillip, & Bauchner, 2005). This study found that the steps that were most difficult to implement were staff training, exclusive breastfeeding, and a rooming in policy. The authors concluded that Baby-Friendly designated hospitals have elevated rates of breastfeeding initiation and exclusivity, and that the increased rates of breastfeeding persisted regardless of demographic factors that are traditionally linked with lower breastfeeding rates.
In another national survey, federal agency researchers surveyed the exposure of nearly two thousand women to six of the Ten Essentials Steps to Successful Breastfeeding. They found that only 8.1% of mothers surveyed experienced five of the six steps measured. Mothers who experienced none of these steps were nearly thirteen times more likely to discontinue breastfeeding before 6 weeks postpartum than those who experienced all 6. It was generally noted that the more of the steps a mother experienced while in the hospital, the greater the likelihood of continuation of breastfeeding initially and up to six months after delivery (DiGirolamo, Grummer- Strawn, & Fein, 2008). It was also noted in the survey that the strongest risk factors for early breastfeeding termination were late breastfeeding initiation, pacifier use, and formula supplementation. It is also relevant, that an early study which helped to set the pace for the BFHI found that during the implementation of the process, breastfeeding rates rose from 58% to 87%, including an increase in U.S. – born African American mothers from 34% to 74% in 1999 ( Phillip et al., 2001).
Data from around the world clearly indicates the positive impact of the BFHI on breastfeeding initiation, duration, exclusivity, and related health outcomes. In 2005 UNICEF collected the following data. It was estimated that over a million healthcare workers worldwide have been trained through the BFHI program. In China it was noted that two years after initiation of the BFHI, exclusive breastfeeding rates doubled in rural areas and increased from 10 percent to 47 percent in urban areas. Nicaragua experienced a similar phenomenon when breastfeeding rates increased from 47 percent prior to implementation of the BFHI to nearly 100 percent in some areas after implementation. Also noted by UNICEF (2005) the rate of rooming in increased from 19 percent to 60 percent, and the practice of supplementing breastfed infants fell from 54 percent to 22 percent after implementation of the BFHI in Poland. In Zambia, implementation the BFHI is credited with a rise in exclusive breastfeeding rates from 16 percent to 35 percent. Finally, a study in the Republic of Belarus found that infants born in hospitals that had implemented the Ten Steps to Successful Breastfeeding were more likely to be breastfed at one year.
The infants were also more likely to be exclusively breastfed at 3 and 6 months of age. There was also a significant reduction in the risk of one or more gastrointestinal tract infections and incidence of atopic eczema. Participation in the BFHI varies in the United States. Some states have facilities which embrace and foster the initiatives, and in other areas, a mother may have to drive many miles to find a Baby-Friendly Hospital. The home states of the authors, Louisiana and New Hampshire, are on opposite ends of the spectrum in terms of Baby-Friendly policies and number of designated facilities. Louisiana has no hospitals that are considered Baby-Friendly, with the closest hospitals in mid Texas or Central Florida (Baby- Friendly USA, 2011). At the present time, New Hampshire has three hospitals within the state which are designated as Baby-Friendly. New Hampshire has also met the Healthy People 2010 goals for breastfeeding initiation, duration and exclusivity, where Louisiana has not (CDC, 2010).
The 2010 Breastfeeding Report Card provides data from a CDC survey that measures the maternity practices in hospitals regarding infant nutrition and care. Maternity practices in Infant Nutrition and Care (mPINC) are measured in each state. The average score across the country was 65 out of a possible 100 points. New Hampshire had the highest overall score in the nation of 81. Louisiana scored a 60 (CDC, 2010). This score may be a reflection of the fact that Louisiana has been ranked 49th for the last nine years in terms of overall child and infant wellbeing (Coila, 2010). Louisiana does foster a program called Guided Infant Feeding Techniques (GIFT). This is a quality improvement and certification program aimed at similar objectives regarding infant feeding practices as the BFHI. Eighteen Louisiana hospitals have received the certification. The two programs vary in that the GIFT is exclusive to Louisiana, is voluntary and self- reporting, and is free.
The BFHI is international, has an external review board, and there is an assessment as well as an annual fee. Both initiatives have a ten step program, but they vary in that the steps in the GIFT are less rigid. The BFHI is considered the gold standard for infant feeding practices in the maternity setting and GIFT is just the beginning, a stepping stone to BFHI. The Breastfeeding Report Card 2010 (CDC, 2010), lists process indicators by which each state is evaluated. In comparison, as indicated in Table 1, New Hampshire displays more favorable process indicators than Louisiana. The higher rates of breastfeeding in New Hampshire may be attributed to the number of Baby- Friendly facilities within the state, and seem to illustrate the impact of the BFHI.
More babies in the United States are being born at Baby-Friendly Facilities, but these births represent less than 4 percent of all U.S. births (Baby- Friendly USA, 2010). Recent CDC data shows that 3 out of every 4 new mothers in the United States now start out breastfeeding. However, rates of breastfeeding at 6 and 12 months as well as rates of exclusive breastfeeding at 3 and 6 months remain low, and are not showing improvement. These statistics point to the fact that mothers want to breast feed, but may not be getting the continued support they need. Mothers still face barriers to breastfeeding. Research is indicated to determine the causes of this trend. In an attempt to advocate for mothers and their babies, letters were sent to hospital and state administrators in New Hampshire and Louisiana (See Appendices A-E). In New Hampshire, emphasis was placed on encouragement and a thank you for a job well done.
In Louisiana, the goal was to increase awareness of the BFHI in general. The letters were sent by certified mail, and a request for a response was included. As a follow up to the letters, phone calls were made to determine the impact. It was found that two hospitals, one in each state are pursuing the BFHI process. Women’s Hospital in Louisiana is working to become GIFT certified, with the goal of becoming a BFHI facility. Catholic Medical Center in New Hampshire, was found to be in the discovery phase of the BFHI process. Both institutions were offered thanks and encouragement regarding the implementation of the process. As a result of the letters, an author of this paper will be speaking at the monthly staff meeting at Elliott Hospital in New Hampshire. The presentation will provide information about the benefits of the BFHI to the infant, mother, and community, as well as explain the steps needed for implementation. Additional follow up in Louisiana is planned through a second project to be conducted in the summer of 2011. Advocacy occurs through community involvement. Mothers who breastfeed can often feel isolated.
There are simple things that a group or individual can do to help promote breastfeeding. A smile, at a mother who is breastfeeding, when appropriate, can go a long way. Complimenting her on her decision to breastfeed could provide even more encouragement. Thanking the management of establishments and spending money with those establishments that promote policies which enhance breastfeeding, and treat the mothers with respect can have a dramatic impact. Checking churches, gyms, clubs, libraries, and other gathering places to see if they have a place provided to allow mothers to comfortably nurse, may make a big difference in the mothers comfort level. In New Hampshire, all state and county fairs provide a nursing trailer or private curtained area for mothers to breastfed. Where these policies are not implemented, acting as an advocate to encourage establishments to provide a place for, and explain the benefits of breastfeeding can help promote positive social change. Local programs for pregnant teens can offer information on breastfeeding.
The number to the local La Leche League Leader, hospital lactation “warm-line” or other breastfeeding support within the community should be provided. In addition, each hospital needs to be aware of and encouraged to join the BFHI. Education can start early. Suggestions to the school board, principles, and teachers in local school districts that information about breastfeeding be included in relevant classes may have impact. Pictures of infants using a bottle suggest that breastfeeding is not necessary. Discussions with physician offices might encourage the removal of materials provided as publicity by formula companies about breastfeeding. These formula packets which supposedly promote breastfeeding can be confusing and inaccurate. Assistance in finding alternative information would seem helpful. Health insurance companies may be approached about what services they cover for breastfeeding mothers and babies. Increased coverage, including pump rentals for healthy infants, would be encouraging. Local groups that address hunger within the community can support breastfeeding, and presentations may be given about the need for breastfeeding support. All of these interventions are cost effective and may inspire change.
Breast milk alone is the ideal nourishment for infants in the first month of life. According to the World Health Organization, 2009 optimal infant and young child feeding means that mothers are empowered to initiate breastfeeding within one hour of birth, breastfeed exclusively for the first 6 months, and continue to breastfeed for two years or more. In addition, infants should be offered only breast milk with the exception of necessary rehydration or medication. Nutritionally adequate solid, semi-solid, and soft foods are to be introduced starting in the sixth month. The BFHI aims to meet these criteria by enhancing child and mother friendly care in hospitals. Initiation of the Ten Steps to Successful Breastfeeding is critical to the process. Although many facilities around the world have adopted these practices and progress has been made, many hospitals are not friendly or helpful in initiating and supporting breastfeeding.
Some hospitals routinely separate mother and baby for no medical reason, and give formula or sugar water via bottles without consulting the mother. “Breastfeeding Support Kits” are often filled with formula samples which can be confusing to a mother who desires to breastfeed exclusively. Work can be done to implement new and more productive policies in these facilities. The BFHI is a wide spread and successful program which has enhanced care to many infants and mothers in hospitals around the world. Although the initiative has grown, there is still work to be done.
There are wide spread discrepancies regarding implementation of the initiative in various countries and states. Barriers to breastfeeding continue to exist. Community involvement and awareness is a key to promoting cost effective measures to increase the number of infants being exclusively breastfed. The benefits of breastfeeding to child, mother and community are known to be great. Through the BFHI and community involvement, the number of children experiencing the life changing benefits of breastfeeding can be increased, and the goals of The World Health Organization regarding breastfeeding can be realized throughout the world.
Baby-Friendly, USA. (2010). Percentage of Live Births at Facilities Designated as Baby-Friendly. Retrieved April 7, 2011 from http://www.babyfriendlyusa.org/eng03.html Baby- Friendly, USA. (2011), Baby Friendly Hospital Initiative USA, Implementing the UNICEF/WHO sponsored BFHI in the United States. Retrieved April 6, 1022, from http://www.babyfriendlyusa.org/eng/01.html Black, R.E., Allen, L.H., Bhutta, Z.A., Caulfield, L.E., Onis, M., Ezzati, M., Mathers, C., Riveria, J. (2008). Maternal and child undernutrition: Global and regional exposures and health consequences. The Lancet, 371(9608), 243-260. Retrieved April 6, 2011, fromhttp://www.the Lancet.com/journals/lancet/article/PII50140-6736 (07)61690-0 Center for Disease Control and Prevention (CDC). (2010). Breastfeeding Report Card- United States, 2010. Retrieved April 6, 2010, from, http://www.cdc.gov/Breastfeeding/data/reportcard.htm Coila, B. (2010). Louisiana ranks 49 out of 50 in health issues, Mississippi last in child health. Retrieved April 7, 2011 from, http://www.examiner.com/healthy-living-in-new-orleans/louisiana-children-rank-49th-out-of-50 DelliFraine, J., Longabeer, I.I., Williams, J. F., Gong, A.K., Delgatto, R.I., Gill, S.L. (2011). Cost comparison of baby friendly and non- baby-friendly hospitals in the United States. Pediatrics, 21.doi: 101542/peds.2010-1591 DiGirolamo, A.M., Grummer-Strawn, L.M., Fein, S.B. (2008). Effect of maternity care practices on breast feeding. Pediatrics 122, S43-S49. doi: 10.1542/peds.2008-1315e Galson, S.K. (2008). Practice applications from the surgeon general. Journal of the American Dietetic Association, 108 (7), 1106. doi: 10.1016/j.jada.2008.04.028 Merewood, A., Mehta, S.D., Chamberlain, L.B., Phillip, B.L., Bachner, H. (2005).
Breastfeeding rates in US Baby- Friendly hospitals: Results of a nationwide Survey. Pediatrics, 116(3), 628-34. Doi: 10.1542/peds.2004-1636 Phillip, B.L., Merewood, A., Miller, L.W., Chawla, n., Murphey- Smith, M.M., Gomes J.S. (2001). Baby-Friendly Hospital Initiative improves breastfeeding initiation rates in a US hospital setting. Pediatrics 108 (3), 677-681. Retrieved from PubMed, April 6, 2011, http://ncbi.nlm.nih.gov/pubmed/11533335 Rubin, R. (2010, July 28). Nursing mothers get a break at work, thanks to health reform. USAToday Online Edition. Retrieved from http://www.usatoday.com/news/health/2010-07-28-breastpumping28_ST_N.htm Smithers, L., McIntyre, E. (2010). The impact of breastfeeding- translating recent evidence for practice. Australian Family Physician, 39 (10): 757-760. Retrieved April, 4, 2011, from PubMed- indexed for MEDLINE, http://www.ncbi.nlm.nih.gov/pubmed/20890478 UNICEF. (2005). 15 years after Innocenti Declaration, Breastfeeding saving six million lives annually. Retrieved April, 4, 2011, from http://www.unicef.org/media/media_30011. Html Whitlock, G., Lewington, S., Sherliker, P., Clarke, R., Emberson, J., Halsey, J., Qizilbash, N. (2009). Body- mass index and cause specific mortality in 900,000 adults: collaborative analyses of 57 prospective studies. The Lancet 373(9669), 1083-1096. World Health Organization. (2009). Retrieved April 4, 2011, from Baby- Friendly Hospital Initiative: http://www.who.int/nutrition/ publications/infantfeeding/9789241594950/en/index.html World Health Organization. (2009). Retrieved April 4, 2011 from The World Health Organizations Infant feeding recommendation: http:// www.who.int/nutrition/topics/infant feeding_recommendation/en/index.html