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["Title","Journal","Full citation","Year of publication","Country in which the study conducted","Setting","BFHI/BFCI step(s)","Study population ","Study aims and objectives ","Summary of results "]
["Baby-Friendly Hospital designation has a sustained impact on continued breastfeeding\n","Maternal and child Nutrition\n","Abd El-Ghany, S. M., A. A. W. Korraa, E. A. Ahmed, I. M. W. Salem, S. A. Eslam, A. A. El-Taweel, and K. Cadwell. “A Survey of Knowledge, Attitudes, and Practices of Providers and Staff at Al-Zahraa University Hospital Regarding the Baby-Friendly Hospital Initiative and the International Code of Marketing Breast Milk Substitutes.” J Perinat Educ 28, no. 4 (2019): 210–17. https://doi.org/10.1891/1058-1243.28.4.210.",2017,"Switzerland\n","Hospital","BHFI overall/all steps ","Postpartum women","To investigate the association of BFH designation and compliance to BF practices of breastfeeding","Four hundred eight providers and staff members who care for breastfeeding mothers and babies at Al-Zahraa University Hospital,Cairo, Egypt were randomly selected to assess their knowledge,attitudes, and practices regarding the Baby-Friendly Hospital Initiative. The majority of the participants scored above 50% on the knowledge and attitude questions, however, on the practice questions only 45.3% scored above 50%, similar to the result obtained 10 years prior. The results indicate that most attention should be focused on developing practice guidelines and monitoring outcomes since knowledge and attitude were found to be adequate. We would recommend self-appraisal of staff as a first step to others whose hospitals are in the process of implementing the Baby-Friendly Hospital Initiative."]
["The Breastfeeding Support and Promotion in Baby-Friendly Maternity Hospitals and Not-as-Yet Baby-Friendly Hospitals in Russia","Breasfeeding Medicine","Abolyan, L. V. “The Breastfeeding Support and Promotion in Baby-Friendly Maternity Hospitals and Not-as-Yet Baby-Friendly Hospitals in Russia.” Breastfeed Med 1, no. 2 (2006): 71–78. https://doi.org/10.1089/bfm.2006.1.71. ",2006,"Russia","Hospital","BHFI overall/all steps ","Postpartum women"," To assess women's perceptions of the quality of medical services in the BFHs.\n\nTo assess the breast feeding practices and trends in the areas with and without BFHs."," A positive effect of Baby Friendly Hospitals (BFH) practice on a number of parameters, such as an increased rate of in-hospital exclusive breastfeeding, mothers' decisions concerning planned duration of breastfeeding, mothers' and babies' health, and maternal knowledge about the necessary measures in BFHs. \n\nMothers appreciated baby-friendly changes, such as rooming-in, breastfeeding on baby's demand, and taking care of their babies by themselves. "]
["Exploring the impact of the Baby-Friendly Hospital Initiative on trends in exclusive breastfeeding","International Breastfeeding Journal","Abrahams, S. W., and M. H. Labbok. “Exploring the Impact of the Baby-Friendly Hospital Initiative on Trends in Exclusive Breastfeeding.” Int Breastfeed J 4 (2009): 11. https://doi.org/10.1186/1746-4358-4-11.",2009,"Bolivia, Brazil, Colombia, Dominican Republic, Egypt, Ghana, Indonesia, Jordan, Kenya, Mali, Niger, Peru, Uganda, Zimbabwe","Country data","BHFI overall/all steps ","Newborns and postpartum women","The purpose of this study is to investigate the contribution of the BFHI to trends in EBF in a group of selected developing countries, through analysis of trends before and after their implementation of the BFHI. \n\nHypothesis: Overall trends in EBF in countries that implemented the BFHI had increased significantly during the time period after BFHI implementation, compared to the time period prior to the program's launch, and also to estimate the program's contribution to upward trends in EBF in the countries under study","Statistically significant upward trends in EBF under two months and under six months, as assessed by whether fitted trends had slopes significantly different from 0, were observed only during the period following BFHI implementation, and not before. \n\nBFHI implementation was associated with average annual increases of 1.54 percentage points in the rate of EBF of infants under two months (p < 0.001) and 1.11-percentage points in the rate of EBF of infants under six months (p < 0.001); however, these rates were not statistically different from pre-BFHI trends."]
["Evaluation of Mothers' Knowledge, Attitudes adn Practice Towards the ten Steps to Successful Breastfeeding in Egypt","Breastfeeding Medicine ","Abul-Fadl, A. M., M. Shawky, A. El-Taweel, K. Cadwell, and C. Turner-Maffei. “Evaluation of Mothers’ Knowledge, Attitudes, and Practice towards the Ten Steps to Successful Breastfeeding in Egypt.” Breastfeed Med 7, no. 3 (2012): 173–78. https://doi.org/10.1089/bfm.2011.0028.",2012,"Egypt","Hospital","BHFI overall/all steps ","Postpartum women","To evaluate the knowledge, attitudes and practice (KAP) of Egyptian mothers towards the Ten Steps. ","Step 3: significant diference between regions; Step 4: significantly delayed more in LE; Poverty: associatied with illiteracy and ignorance, which is prevalent among older family members who can have adverse effects on BF practices. Step 6: two thirds of mothers in both UE and LE intriduce herbal drinks or decoctions to their babies in the first 6 months. 1 third in both regions give formula before their babies are 6 months; Step 7: practiced by almost all mothers in both regions; Step 8: most; Step 9: a large proportion of mothers report offering pacifiers to their babies. Poverty: associatied with illiteracy and ignorance, which is prevalent among older family members who can have adverse effects on BF practices.\nRarely were HW mentioned as a source of BF information "]
["Compliance of a Baby-Friendly Designated Hospital in Ghana With the WHO/UNICEF Baby and Mother-Friendly Care Practices","Journal of Human Lactation","Agbozo, F., D. Ocansey, P. Atitto, and A. Jahn. “Compliance of a Baby-Friendly Designated Hospital in Ghana With the WHO/UNICEF Baby and Mother-Friendly Care Practices.” J Hum Lact 36, no. 1 (2020): 175–86. https://doi.org/10.1177/0890334419848728.",2019,"Ghana","Hospital","BHFI overall/all steps ","Health workers, pregnant women,  postpartum mothers, clinical staff","To reassess compliance of a BFH with the Ten Steps to Successful Breastfeeding, the International Code of Marketing of Breast-milk Substitutes, HIV and Infant Feeding, and Mother-Friendly Care following the WHO/UNICEF BFHI Global Criteria","The facility passed the criteria for full compliance with the International Code (86%) but failed other components. Compliance with the Ten Steps was moderate (55%). \n\nStep 7 about rooming-in (84%) and Step 9 about human milk substitutes (100%) were passed, whereas Step 1 about written breastfeeding policies (0%), Step 2 about staff training (7%), and Step 4 about early breastfeeding initiation (31%) were met the least. \n\nCompliance with Mother-Friendly Care (34%) and HIV and Infant Feeding (47%) were low. \n\nMain implementation gaps were unavailability of policies and staff's inadequate knowledge about Baby-Friendly practices"]
["Postpartum depressive symptoms following implementation of the 10 steps to successful breastfeeding program in Kinshasa, Democratic Republic of Congo: A cohort study","PLoS Med","Agler, R. A., P. N. Zivich, B. Kawende, F. Behets, and M. Yotebieng. “Postpartum Depressive Symptoms Following Implementation of the 10 Steps to Successful Breastfeeding Program in Kinshasa, Democratic Republic of Congo: A Cohort Study.” PLoS Med 18, no. 1 (2021): e1003465. https://doi.org/10.1371/journal.pmed.1003465.",2021,"Democratic Republic of Congo","Hospital","Steps 1-9 versus Steps 1-10 comparison","Newborns and postpartum women","Our objective was to quantify the association of implementing Steps1-9 or Steps1-10 on postpartum depressive symptoms and test whether this associ-ation was mediated by breastfeeding difficulties","The prevalence of probable depression at 14 weeks postpartum was 18% for SOC, 11% for Steps 1-9, and 8% for Steps 1-10.\nConclusions: we have shown that the implementation of the BFHI steps is associated with a decrease in depression symptoms at 14 weeks postpartum. The findings also suggest that this association is mediated by difficulties with breastfeeding. These results were robust across analytical approaches and different definitions of breastfeeding difficulties and probable depression. Given the numerous health consequences of PPD, the BFHI may then provide a general benefit to both maternal and infant health owing to the simple routine discussions about breastfeeding that the BFHI mandates, with this effect occurring in addition to those afforded by exclusive breastfeeding "]
["Breastfeeding Practices and Barriers to Implementing the Ten Steps to Successful Breastfeeding in Mississippi Hospitals","Journal of Human Lactation","Alakaam, A., J. Lemacks, K. Yadrick, C. Connell, H. W. Choi, and R. G. Newman. “Maternity Nurses’ Knowledge and Practice of Breastfeeding in Mississippi.” MCN Am J Matern Child Nurs 43, no. 4 (2018): 225–30. https://doi.org/10.1097/nmc.0000000000000437.",2018,"United States","Hospital","BHFI overall/all steps ","Health workers"," (a) explore the status of overall Ten Steps policies and practices (Ten Steps level of implementation) in Mississippi hospitals, \n\n(b) assess associations between hospitals' characteristics and Ten Steps implementation levels, and \n\n(c) identify barriers to implementing the Ten Steps in Mississippi hospitals.","None of the 31 hospitals had a BFHI designation at the time of the research. \n\nThe researcher classified implementation in 29% of hospitals as moderate and in 71% as partial. \n\nThe hospital level of implementation was significantly positively associated with the hospital delivery rate along with the hospital cesarean section rate per year. \n\nThe main barriers for the implementation process of the Ten Steps reported were resistance to new policies, limited financial and human resources, and lack of support from national and state governments.\n"]
["Assessment of the Baby Friendly Hospital Initiative Implementation in the Eastern Mediterranean Region","Children","Al-Jawaldeh, A., and A. Abul-Fadl. “Assessment of the Baby Friendly Hospital Initiative Implementation in the Eastern Mediterranean Region.” Children (Basel) 5, no. 3 (2018). https://doi.org/10.3390/children5030041.",2018,"East Mediterranean Region: Afghanistan, Bahrain, Djibouti, Egypt, Jordan, Iran, Iraq, Kuwait, Lebanon, Libya, Morocco, the occupied territory of Palestine, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen","Hospital","BFHI implementation per country","Academic review-countries ","To review the status and progress of BFHI implementation in the EMR countries in relation to the nutritional status of children under five and to discuss challenges towards achieving universal BFH","BFHI was not implemented in 22.7% of EMR countries. Designated Baby-Friendly hospitals totaled 829 (group I: 78.4%, group II: 9.05%; group III: 7.36%; group: IV5.19%). \n\nCountries with advanced nutrition transition had the highest implementation of BFHI but the lowest breastfeeding continuity rates. \n\nOn the other hand, poor nutritional status and emergency states were linked with low BFHI implementation and low exclusive breastfeeding rates but high continuity rates.  Early initiation and longer duration of breastfeeding correlated negatively with overweight and obesity (p< 0.001).\n\nIn countries with emergency states, breastfeeding continues to be the main source of nourishment"]
["Baby-friendly hospital practices and birth costs","Birth","Allen, J. A., H. B. Longenecker, C. G. Perrine, and K. S. Scanlon. “Baby-Friendly Hospital Practices and Birth Costs.” Birth 40, no. 4 (2013): 221–26. https://doi.org/10.1111/birt.12062.",2015,"United States","Hospital","BHFI overall/all steps ","Postpartum women","To build on prior research by exploring the cost of a birth by the number of breastfeeding supportive practices in a place at a hospital","Sixty-one percent of hospitals had ideal practice on 3-5 of the 10 steps, whereas 29 percent of hospitals had ideal practice on 6-8. \n\nAdjusted analyses of uncomplicated births revealed a higher but nonsignificant increase in any of the birth categories (all births, $19; vaginal, $15; cesarean section, $39) with each additional breastfeeding supportive maternity care practice in place."]
["Health Professionals' Perspectives on Breastfeeding Support Practices","Saudi Journal of Medicine and Medical Sciences","Al-Madani, M. M., and L. Y. Abu-Salem. “Health Professionals’ Perspectives on Breastfeeding Support Practices.” Saudi J Med Med Sci 5, no. 2 (2017): 116–23. https://doi.org/10.4103/1658-631x.204875.",2017,"Saudi Arabia","Hospital","BHFI overall/all steps ","Health workers","Assessed breastfeeding practices using the ten steps to successful breastfeeding, as outlined by the Baby-Friendly Initiative","Approximately, two-thirds(64%) of the hospital administrators stated that the hospital did not provide in-service breastfeeding-related training.\nOne-fourth(29%) indicated that there was in-service training related to the advantages of breastfeeding in the form of seminars, workshops or conferences.\nThere were no breastfeeding supporting policies followed at the hospitals as per those recommended by BFHI. \nMothers with breastfeeding problems were not referred for help and follow-up phone calls were not made to postpartum women after discharge. \nHealthcare professionals indicated that there were no hospital-based breastfeeding support groups, lactation consultants/specialists or lactation management unit available"]
["Breastfeeding Support in Spanish Neonatal Intensive Care Units and the Baby-Friendly Hospital Initiative: A National Survey","Journal of Human Lactation","Alonso-Diaz, C., I. Utrera-Torres, C. de Alba-Romero, B. Flores-Anton, D. Lora-Pablos, and C. R. Pallas-Alonso. “Breastfeeding Support in Spanish Neonatal Intensive Care Units and the Baby-Friendly Hospital Initiative: A National Survey.” Journal of Human Lactation 32, no. 4 (2016): 613–26. https://doi.org/10.1177/0890334416658246.",2016,"Spain","Hospital","BHFI overall/all steps ","Health workers","To compare breastfeeding support in Spanish NICUs in hospitals with BFHI accreditation or in the process of being accredited (group 1) with NICUs in hospitals that have not yet begun this initiative (group 2)","Of the 141 participating NICUs, 129 (91%) responded to the questionnaire: 38 NICUs from group 1 and 91 NICUs from group 2. \nGroup 1 had implemented a higher number of breastfeeding support measures than group 2. \nThere were significant differences in 18 measures related to steps 2, 4, 5, 7, and 8 of the Neo-BFHI. \nIn addition, a comparison of NICUs in hospitals with full accreditation (7 of 129) with those in group 2 revealed significant differences in 7 measures pertaining to steps 2, 5, 8, and 9.\n\nRecommended: Working according to the BFHI accreditation standards improves practices"]
["Reassessment of Baby-friendly Hospitals in Brazil","Journal of Human Lactation","Araujo, M. de F. M. de, and B. de A. S. Schmitz. “Reassessment of Baby-Friendly Hospitals in Brazil.” Journal of Human Lactation 23, no. 3 (2007): 246–52. https://doi.org/10.1177/0890334407303899.",2007,"Brazil","Hospital","BHFI overall/all steps ","Health workers","To reassess, in 2002,all BFHs certified in Brazil until the year 2000,  to determine if the Ten Steps to Successful Breast feeding were being met and to evaluate their respective adherence rates, using for the first time an instrument specifically developed for this purpose","Of the 167 eligible Baby-friendly Hospitals assessed, 137 (82%) met all of the10 steps. \n\nSteps 2 and 3 presented the lowest adherence rates (91% and 92%, respectively), followed by steps 4, 5, and 10, with 95% each. \n\nSteps 7 and 9 reflected the highest adherence rate of 99% among all eligible Baby-friendly Hospitals.\n\nRecommendations: Intensify regular health training programs for professionals working in Baby-friendly Hospitals on managing and promoting breastfeeding and to implement strategies that favour steps 3 and 10, to further promote and support breastfeeding before and after delivery.\n\nA continuous monitoring system will strengthen the initiative and improve the BFH. \n\nNew assessment tools may be used to assess precisely the difficulties with compliance with requirements and provide a database for future BFH reassessments\n\nFor step 10 to be met, a follow-up system must be available, inside or outside a hospital, where mothers can be referred after discharge."]
["External evaluation and self-monitoring of the Baby-friendly Hospital Initiativeâ€™s maternity hospitals in Brazil","International Breastfeeding Journal","Araujo, Renara Guedes, Vania de Matos Fonseca, Maria Ines Couto de Oliveira, and Eloane Goncalves Ramos. “External Evaluation and Self-Monitoring of the Baby-Friendly Hospital Initiative’s Maternity Hospitals in Brazil.” International Breastfeeding Journal 14 (2019). https://doi.org/10.1186/s13006-018-0195-4.",2019,"Brazil","Hospital","BHFI overall/all steps ","Health workers","To verify if the self-monitoring system fulfils its role of enabling accredited hospitals to assess and improve their compliance with the BFHI criteria. In this sense, we will analyse the self-monitoring evaluation results and compare them with those of the external reassessment.","Self-monitoring was performed in all years from 2010 to 2015 by 143 BFHI accredited hospitals. \nThe trend of the levels of compliance with BFHI's criteria according to self-monitoring evaluations was stable over the assessed period. Most criteria presented compliance above 70%, except Step 4 (skin-to-skin contact and breastfeeding in the first hour of life), with mean compliance of 67%. Steps 1 (written policy), 7 (rooming-in) and 9(give no artificial teats) showed mean compliance above 90%. \nRegarding the external evaluation carried out in2015, the criteria with lowest compliance were Step 4 and Woman-Friendly care, both below 50%. Steps 9 and 10(refer mothers to breastfeeding support groups) reached levels of compliance above 90%.\n For 2015, self-monitoring provided significant higher compliance levels than those from external evaluations in most criteria, except Step 3(prenatal information on breastfeeding) and Step 10. There was a difference of more than 30% points between evaluations of Steps 1 (written policy), 2 (training), 5 (show mothers how to breastfeed), Woman-Friendly Care and father or mother stay with their newborn"]
["Re-assessment of selected Baby-Friendly maternity facilities in Accra, Ghana","International Breastfeeding Journal","Aryeetey, R. N. O., and C. L. Antwi. “Re-Assessment of Selected Baby-Friendly Maternity Facilities in Accra, Ghana.” International Breastfeeding Journal 8, no. 15 (2013). http://www.internationalbreastfeedingjournal.com/content/pdf/1746-4358-8-15.pdf.",2013,"Ghana","Hospital","BHFI overall/all steps ","Health workers, pregnant women, postnatal mothers","The current study was designed to re-assess six selected hospitals in the capital of Ghana in order to determine adherence to the Ten Steps and the Code.","In 2010, the six facilities recorded a total of 26,339 deliveries. At discharge, the weighted exclusive breastfeeding rate was 93.8%. None of the facilities adhered completely to the Ten Steps. Overall, the rate of adherence to the Ten Steps was 42% (range = 30 - 70%). \nNo facility met the criteria for Steps One and Two. Only Step Seven was adhered to by all facilities. Overall compliance with the Code was about 54%. \nTrained staff attrition, high client-staff ratios, inadequate in-service training for new staff, and inadequate support for regional and national program monitoring were identified as barriers to adherence."]
["Applying a knowledge translation model on the up take of the Baby Friendly Health Initiative in the Australian health care system","Women and birth","Atchan, M., D. Davis, and M. Foureur.  “Applying a Knowledge Translation Model to the Uptake of the Baby Friendly Health Initiative in the Australian Health Care System.” Women Birth 27, no. 2 (2014): 79–85. https://doi.org/10.1016/j.wombi.2014.03.001.",2014,"Australia","Hospital","BHFI overall/all steps ","Academic research article","To identify a theory and model to examine where and how barriers occur in the gap between evidence and practice in the uptake of the BFHI in Australia","Knowledge translation theory and there search to practice pipeline model are used to examine the identified barriers to BFHI implementation and accreditation in Australia.\n\nRecommendations in the form of specific targeted strategies to facilitate knowledge transfer and supportive practices into the Australian healthcare system and current midwifery practice are included."]
["An historical document analysis of the introduction of the Baby Friendly Hospital Initiative into the Australian setting","Women and birth : Journal of the Australian College of Midwives","Atchan, M., D. Davis, and M. Foureur. “An Historical Document Analysis of the Introduction of the Baby Friendly Hospital Initiative into the Australian Setting.” Women Birth 30, no. 1 (2017): 51–62. https://doi.org/10.1016/j.wombi.2016.07.004.",2016,"Australia","Hospital","BHFI overall/all steps ","Records: Documents reviewed ","To analyse the socio political challenges associated with implementing a global programme into a national setting via an examination of the influences on the early period of implementation of the Baby Friendly Hospital Initiative in Australia","Four major themes were identified: \"a breastfeeding culture\"; \"resource implications\"; \"ambivalent support for breastfeeding and the BFHI\" and \"business versus advocacy\". \"A breastfeeding culture\" included several subthemes.\nNo tangible support for breastfeeding generally, or the Baby Friendly Hospital Initiative specifically, was identified. \nAustralian policy did not follow international recommendations. \nThere were no financial or policy incentives for BFHI implementation.\n\nTo effect the translation of evidence into practice carriage of a program by a dedicated multisectoral nation committee to oversee all aspects of implementation, evaluate progress and ensure accountability is essential."]
["An instrumental case study examining the introduction and dissemination of the Baby Friendly Health Initiative in Australia: Participantsâ€™ perspectives","Women and Birth","Atchan, M., D. Davis, and M. Foureur. “An Instrumental Case Study Examining the Introduction and Dissemination of the Baby Friendly Health Initiative in Australia: Participants’ Perspectives.” Women Birth 31, no. 3 (2018): 210–19. https://doi.org/10.1016/j.wombi.2017.08.130.",2018,"Australia","National setting","BHFI overall/all steps ","Key Informants Participants from UNICEF, Australlian College of Midwives, maternity and community health services, the Australian government and volunteer organisations","To examine the introduction and dissemination of the Baby-friendly Hospital Initiative into the Australian national setting.","Data analysis revealed three main themes influencing the BFHI and dissemination of BFHI Australia: Rhetoric versus Reality; Human and Fiscal Resourcing and, Governance within Competing Agendas. Participants identified different perceptions of the issues relevant to the support of breastfeeding, due in part due to their diversity of backgrounds and association with the dissemination of BFHI Australia. \n\nDissemination of BFHI Australia is hampered by multi-level systems issues. Participants revealed a positive perception of the BFHI whilst identifying that its interpretation and expansion in Australia had been negatively influenced by intangible government support and suboptimal capacity building. BFHI's advocacy agenda competed with BFHI Australia's need for financial viability. \n\nThe role of government is critical to the ongoing success of the BFHI in Australia according to all participants. Effective governance of BFHI Australia has been and continues to be central to its capacity for successful dissemination. Consensus and collaboration between key stakeholders was recognised as an effective strategy to increase capacity for BFHI uptake and to assist BFHI Australia to meet its aims. Widespread  stakeholder collaboration and tangible political endorsement was seen as a way to move the strategy forward. "]
["The impact of the Baby Friendly Health Initiative in the Australian health care system: A critical narrative review of the evidence","Breastfeeding review","Atchan, M., D. Davis, and M. Foureur. “The Impact of the Baby Friendly Health Initiative in the Australian Health Care System: A Critical Narrative Review of the Evidence.” Breastfeed Rev 21, no. 2 (2013): 15–22.",2013,"Australia","Literature search in data bases","BHFI overall/all steps ","Health facility level","Discuss a variety of issues relevant to the uptake and support of breastfeeding and the BFHI, utilising Australia as a case study.","Whilst it enjoys 'in principle 'policy support, Australia also suffers from a lack of uniformity in uptake and perception of the benefits of BFHI at all levels of the health system; Managerial support hampered by lack of funding. \n\nThe degree of comprehensive ongoing support in the national agenda to protect, promote, and support breastfeeding appears to be minimal.\n\nFurther research to identify the extent of BHFI implementation in Australia and the impact on breastfeeding is required urgently to provide policy makers with evidence on which to base specific recommendations and facilitate governmental support for women to achieve their breastfeeding goals."]
["Medical education and the quality improvement spiral: A case study from Mpumalanga, South Africa","African Journal of Primary Health Care and Family Medicine","Bac, M., A. M. Bergh, M. E. Etsane, and J. Hugo. “Medical Education and the Quality Improvement Spiral: A Case Study from Mpumalanga, South Africa.” Afr J Prim Health Care Fam Med 7, no. 1 (2015). https://doi.org/10.4102/phcfm.v7i1.738.",2015,"South Africa","Hospital","BHFI overall/all steps ","Medical students","To describe the process of inducting students into a longitudinal quality-improvement project, using the topic of the Mother- and Baby-Friendly Initiative as a case study; and to explore the possible contribution of a quality-improvement project to the development of student competencies","Activities in each rotation varied according to the needs identified through the application of the quality-improvement cycle in consultation with the local health team. The development of student competencies is described according to the roles of a medical expert in the CanMEDS framework: collaborator, health advocate, scholar, communicator, manager and professional. The exposure to the real-life situation in South African public hospitals had a great influence on many students, who also acted as catalysts for transforming practice"]
["Effectiveness of Baby-friendly community health services on exclusive breastfeeding and maternal satisfaction: a pragmatic trial","Maternal and Child Nutrition","Baerug, A., O. Langsrud, B. F. Loland, E. Tufte, T. Tylleskar, and A. Fretheim. “Effectiveness of Baby-Friendly Community Health Services on Exclusive Breastfeeding and Maternal Satisfaction: A Pragmatic Trial.” Maternal and Child Nutrition 12, no. 3 (2016): 428–39. https://doi.org/10.1111/mcn.12273.",2016,"Norway","Hospital","BHFI overall/all steps ","Postpartum women","The aim of this pragmatic cluster quasi-randomised controlled trial was to assess the effectiveness of implementing the Baby-friendly Initiative (BFI) in community health services","Women in the intervention group were more likely to breastfeed exclusively compared with those who received routine care: 17.9% vs.14.1% until 6 months [cluster adjusted odds ratio (OR) = 1.33; 95% confidence interval (CI): 1.03, 1.72;P= 0.03],41.4% vs. 35.8% until 5 months [cluster adjusted OR = 1.39; 95% CI: 1.09, 1.77;P= 0.01], and 72.1% vs. 68.2%for any breastfeeding until 6 months [cluster adjusted OR = 1.24; 95% CI: 0.99, 1.54;P= 0.06]. \n\nThe intervention had no effect on breastfeeding until 12 months. \n\nMaternal breastfeeding experience in the two groups did not differ, neither did perceived breastfeeding pressure from staff in the community health services"]
["Health Facility Staff Training for Improving Breastfeeding Outcome: A Systematic Review for Step 2of the Baby-Friendly Hospital Initiative","Breastfeeding Medicine","Balogun, O. O., A. Dagvadorj, J. Yourkavitch, K. da Silva Lopes, M. Suto, Y. Takemoto, R. Mori, P. Rayco-Solon, and E. Ota. “Health Facility Staff Training for Improving Breastfeeding Outcome: A Systematic Review for Step 2 of the Baby-Friendly Hospital Initiative.” Breastfeed Med 12, no. 9 (2017): 537–46. https://doi.org/10.1089/bfm.2017.0040.",2017,"Sweden, Australia, Canada, United States and Brazil","Hospital","BHFI overall/all steps ","Health workers","Provide evidence about the effect of training healthcare staff in hospitals and birth centers on breastfeeding outcomes.","The studies were conducted in 5  countries  and  involved  390  healthcare  staff.  Provision  of  educational  interventions  aimed  at  increasing knowledge and practice of BFHI and support was found to improve health worker's knowledge, attitude, and compliance with the BFHI practices.\n\nIn one study, the rate of exclusive breastfeeding increased at the intervention  site  but  no  differences  were  found  for  breastfeeding  initiation  rates.  \n\nAll  included  studies  had  methodological limitations, and study designs and methodologies lacked comparability"]
["Monitoring breastfeeding rates in Italy","Acta Paediatrica","Banderali, G., E. Riva, S. Scaglioni, C. Agostoni, and M. Giovannini. “Monitoring Breastfeeding Rates in Italy.” Acta Paediatr Suppl 91, no. 441 (2003): 6–8. https://doi.org/10.1111/j.1651-2227.2003.tb00639.x.",2003,"Italy","Hospital","BHFI overall/all steps ","Postpartum women","To  determine  the  rates  of initiation  and  duration  of breastfeeding  in  Italy  in 1995 and  1999,and to examine the adherence to the ten steps to successful breastfeeding recommended by WHO","Initiation  and  duration  of breastfeeding  increased  during  the  1995â€“1999  period  (p< 0.0001).  \n\nThe  rate  of  breastfeeding  at discharge and when the infants where 3 months of age was 83% and 42% in 1995, and 89% and66%  in  1999.  \n\nThe  rate  of  exclusive/predominant  breastfeeding  at  discharge  was  higher  in  1999than 1995 (78% vs 72%)."]
["ROLE OF BABY-FRIENDLY HOSPITAL CARE IN MATERNAL ROLE COMPETENCE","Nursing for Women's Health","Barabach, L., S. M. Ludington-Hoe, D. Dowling, and M. Lotas. “Role of Baby-Friendly Hospital Care in Maternal Role Competence.” Nurs Womens Health 21, no. 2 (2017): 96–107. https://doi.org/10.1016/j.nwh.2017.02.006.",2017,"United States","Hospital","Step 4","Postpartum women"," To determine women's perceptions of their levels of maternal role competence at discharge from a Baby-Friendly hospital. "," Participants reported positive perception (high maternal self-efficacy scores) of their maternal \nrole competence on day of discharge.\n\nOnly step 4 of BFHI was practiced by the participants"]
["Evaluation of a Practice-Development Initiative to Improve Breastfeeding Rates","Perinatal Education","Barnes, M., J. Cox, B. Doyle, and R. Reed. “Evaluation of a Practice-Development Initiative to Improve Breastfeeding Rates.” J Perinat Educ 19, no. 4 (2010): 17–23. https://doi.org/10.1624/105812410x530893.",2010,"Australia","Hospital","BHFI overall/all steps ","Multiple: 1. Postpartum women\n2. Health workers\n3. Charts","The practice-development initiative aimed to improve hospital-based breastfeeding rates through the implementation of The Ten Steps to Success-ful Breastfeeding.","The introduction of the initiative's educational program, together with ongoing support and policy change, increased;\n1. breastfeeding rates over time. \n2. Clients' preparation for breastfeeding and their satisfaction."]
[" Trends in roomingâ€\u0090in practices among hospitals in the United States","Birth","Barrera, C. M., J. M. Nelson, E. O. Boundy, and C. G. Perrine. “Trends in Rooming-in Practices among Hospitals in the United States, 2007-2015.” Birth 45, no. 4 (2018): 432–39. https://doi.org/10.1111/birt.12359.",2018,"United States","Hospital","Step 4","Hospital: Mother-baby unit managers","Rooming-in, or keeping mothers and infants together throughout the birth hospitalization, increases breastfeeding initiation and duration, and is one of the Ten Steps to Successful Breastfeeding. The Centers for Disease Control and Prevention’s (CDC) Maternity Practices in Infant Nutrition and Care (mPINC) survey is a biennial census of all birth facilities in the United States and its territories. Data from the 2007–2015 mPINC surveys were used to assess trends in the prevalence of hospitals with most (≥90%) infants rooming-in more than 23 hours per day (ideal practice). Hospital practices among breastfed infants not rooming-in at night and reasons why hospitals without ideal rooming-in practices removed healthy, full-term, breastfed infants from their mothers’ rooms were also analyzed.","Results—The percentage of hospitals with ideal practice increased from 27.8% in 2007 to 51.4% in 2015. Most breastfed infants who were not rooming-in were brought to their mothers at night for feedings (91.8% in 2015). Among hospitals without ideal rooming-in practices, the percentage removing 50% or more of infants from their mothers’ rooms at any point during the hospitalization decreased for all reasons surveyed during 2007–2015; however, in 2015, hospitals still reported regularly removing infants for hearing tests (73.2%), heel sticks (65.5%), infant baths (40.2%), pediatric rounds (35.5%), and infant photos (25.4%). Conclusions—Hospital implementation of rooming-in increased 23.6 percentage points during 2007–2015. Continued efforts are needed to ensure that all mothers who choose to breastfeed receive optimal lactation support during the first days after giving birth."]
["Closing the quality gap: promoting evidence-based breastfeeding care in the hospital.","Pediatrics","Bartick, M., A. Stuebe, K. R. Shealy, M. Walker, and L. M. Grummer-Strawn. “Closing the Quality Gap: Promoting Evidence-Based Breastfeeding Care in the Hospital.” Pediatrics 124, no. 4 (2009): e793-802. https://doi.org/10.1542/peds.2009-0430.",2009,"United States","Hospital","BHFI overall/all steps ","Records","To give an overview of BFHI in USA and how it can be improved","Implementation of  BFHI steps particularly 2,6 and 7 is low. \nEnhancing implementation of BFHI can improve infant outcomes. Therefore lobbying for inclusion of BFHI in the agenda of policy makers and politicians becomes vital.\n\nBarriers and enabling facilitators identified; Barriers: 1. Formula marketing; 2.Attitude and beliefs towards breast milk and formula.\n\nEnablers:  1. Training of providers including decision makers\n2.  Recognition of excellence, such as through Baby-Friendly hospital designation\n3. public reporting of indicators of the\nquality of breastfeeding care\n4. Incentives\n5. Regional collaboratives"]
["Trends in Breastfeeding Interventions, Skin-to-Skin Care, and Sudden Infant Death in the First 6 Days after Birth","Pediatrics","Bartick, M., M. E. Boisvert, B. L. Philipp, and L. Feldman-Winter. “Trends in Breastfeeding Interventions, Skin-to-Skin Care, and Sudden Infant Death in the First 6 Days after Birth.” J Pediatr 218 (2020): 11–15. https://doi.org/10.1016/j.jpeds.2019.09.069.",2020,"United States","Hospital","Step 4+G216G262G225:GG1:G256","Records: Breast feeding report cards","To determine if implementation of skin-to-skin care and the Baby-Friendly Hospital Initiative (BFHI) contributes to sudden unexpected infant death (SUID) and asphyxia in the first 6 days after birth.","Results Nationally,births in Baby-Friendly facilities rose from 1.8% to 18.3% and the percentage of facilities in which most dyads experienced skin-to-skin care rose from 40% to 83%. SUID prevalence among infants <7 days was rare (0.72% of neonatal deaths)and decreased significantly from 2004-2009 compared with 2010- 2016,from 0.033 per 1000 live births to 0.028, OR0.85 (95%CI0.77,0.94).\n\nIn Massachusetts, births in Baby Friendly facilities rose from 2.8% to 13.9% and skin-to-skin care rose from 50% to 97.8%. SUID prevalence decreased from 2010-2016 compared with 2004-2009: OR0.32(95%CI0.13,0.82), with asphyxia deaths during the 13-year period. Conclusion Increasing rates of breastfeeding initiatives and skin-to-skin care are temporally associated with decreasing SUID prevalence in the first 6 days after birth in the US and Massachusetts."]
["Are breastfeeding rates higher among mothers delivering in Baby Friendly accredited maternity units in the UK?","International Journal of Epidemiology","Bartington, S., L. J. Griffiths, A. R. Tate, and C. Dezateux. “Are Breastfeeding Rates Higher among Mothers Delivering in Baby Friendly Accredited Maternity Units in the UK?” Int J Epidemiol 35, no. 5 (2006): 1178–86. https://doi.org/10.1093/ije/dyl155.",2006,"UK","Hospital","BHFI overall/all steps ","Newborns and postpartum women","To determine whether breastfeeding rates in the UK were higher among mothers delivering in Baby Friendly accredited maternity units, using data from the Millennium Cohort Study. Specifically we assessed breastfeeding initiation and the prevalence of any breastfeeding at 1 month after adjustment for maternal factors known to influence a mother's decision to breastfeed. ","- Mothers who delivered in maternity units holding the Baby Friendly Full Accreditation Award were 10% more likely to start breastfeeding, having accounted for area, and individual social and demographic factors already known to be associated with  breastfeeding.                                          \n- We did not find any similar effect for delivery in a maternity unit holding the Certificate of Commitment.                                  \n - Breastfeeding initiation was not significantly associated with delivery in a certificated unit.                      - Delivery in an accredited or certificated unit was not associated with  breastfeeding prevalence at 1 month \n- Our findings suggest that implementation of the UNICEF UK Baby Friendly Initiative in isolation is unlikely to be effective in extending the duration of breastfeeding"]
["Outcomes from the Centers for Disease Control and Prevention 2018 breastfeeding report card: public policy implications. ","Pediatrics","Bass, J. L., T. Gartley, and R. Kleinman. “Outcomes from the Centers for Disease Control and Prevention 2018 Breastfeeding Report Card: Public Policy Implications.” J Pediatr 218 (2020): 16-21.e1. https://doi.org/10.1016/j.jpeds.2019.08.059.",2020,"United States","Hospital","BHFI overall/all steps ","Records: Cards","To compare the impact of Baby-Friendly designation vs rates of in-hospital breastfeeding initiation on breastfeeding outcomes at 3, 6, and 12 months postdischarge.","Statewide breastfeeding initiation rates were positively associated with targeted breastfeeding out-comes. Similar associations were not found for Baby-Friendly hospital designation penetrance.\n\nSpecific practices which can promote successful breastfeeding practices  need to be identified and promoted.\n\nDesignation of BFHI is not enough to improve breastfeeding. Understanding contextual factors associated with breastfeeding might be helpful "]
["A systematic review of structured compared with non-structured breastfeeding programmes to support the initiation and duration of exclusive and any breastfeeding in acute and primary health care settings","Maternal and Child Nutrition","Beake, Sarah, Carol Pellowe, Fiona Dykes, Virginia Schmied, and Debra Bick. “A Systematic Review of Structured Compared with Non-Structured Breastfeeding Programmes to Support the Initiation and Duration of Exclusive and Any Breastfeeding in Acute and Primary Health Care Settings.” Maternal and Child Nutrition 8, no. 2 (2012): 141–61. https://doi.org/10.1111/j.1740-8709.2011.00381.x.",2012,"Different high/middle  income countries","Hospital","BHFI overall/all steps ","Multiple: 1. Postpartum women\n2. Lay counselors\n3. Health workers","Policies and guidelines have recommended that structured programmes to support breastfeeding should be introduced.The objective of this review was to consider the evidence of outcomes of structured compared with non-structured breastfeeding programmes in acute maternity care settings to support initiation and duration of exclusive breastfeeding.Quantitative and qualitative studies were considered.Primary outcomes of interest were initiation of breastfeeding and duration of exclusive breastfeeding.","Most studies found a statistically significant improvement in breastfeeding initiation following introduction of a structured breastfeeding programme, although effect sizes varied.The impact on the duration of exclusive breastfeeding and duration of any breastfeeding to 6 months was also evident, although not all studies found statistically significant differences. Despite poor overall study quality, structured programmes compared with standard care positively influence the initiation and duration of exclusive breastfeeding and any breastfeeding. In health care settings with low breastfeeding initiation and duration rates, structured programmes may have a greater benefit. Few studies controlled for any potential confounding factors, and the impact of bias has to be considered."]
[" Barriers and facilitators to implementing the baby-friendly hospital initiative in neonatal intensive care units. ","Journal of Obstetric, Gynecologic & Neonatal ","Benoit, B., and S. Semenic. “Barriers and Facilitators to Implementing the Baby-Friendly Hospital Initiative in Neonatal Intensive Care Units.” J Obstet Gynecol Neonatal Nurs 43, no. 5 (2014): 614–24. https://doi.org/10.1111/1552-6909.12479.",2014,"Canada","Hospital","BHFI overall/all steps ","Multiple Key Informants: 1.Lactation consultants\n2. Medical and nursing managers\n3. Neonatal nurse practitioners","To explore manager, educator, and clinical leader perceptions of barriers and facilitators to implementing Baby-Friendly practice in the neonatal intensive care unit (NICU)","Participants valued breastfeeding and family-centered care yet identified numerous contextual barriers to Baby-Friendly care including infant health status, parent/infant separation, staff workloads and work patterns, gaps in staff knowledge and skills, and lack of continuity of breastfeeding support. Facilitators included breastfeeding education, breastfeeding champions, and interprofessional collaboration; Barriers include-1. infant health status, 2. Parent/infant separation, 3. Staff workloads and work patterns, 4. Gaps in staff knowledge and skills, 5. Lack of continuity of breastfeeding support"]
["Establishing the Baby - Friendly Community Initiative in Italy: Development, Strategy, and Implementation","Journal of Human Lactation","Bettinelli, M. E., E. M. Chapin, and A. Cattaneo. “Establishing the Baby-Friendly Community Initiative in Italy: Development, Strategy, and Implementation.” J Hum Lact 28, no. 3 (2012): 297–303. https://doi.org/10.1177/0890334412447994.",2012,"Italy","Community ","BFCI only  ","Health workers","To describe the development, strategy, and implementation of the BFCI in Italy","There is now one fully accredited Baby-Friendly Community in Italy.\nSeventeen other communities are working on the various stages.\n\n"]
["Exclusive breastfeeding at the point of discharge of high-risk newborns at a Neonatal Care Intensive Care Unit and the factors associated with this practice.","Jornal de Pediatria","Bicalho-Mancini, P. G., and G. Velasquez-Melendez. “Exclusive Breastfeeding at the Point of Discharge of High-Risk Newborns at a Neonatal Intensive Care Unit and the Factors Associated with This Practice.” Jornal de Pediatria 80, no. 3 (2004): 241–48.",2004,"Hong Kong","Hospital","Becoming BFH and post BFH","Newborns ","To study the rate of exclusive breastfeeding at the moment of hospital discharge of newborns admitted to a neonatal Intensive Care Unit and to analyse potential risk factors","The exclusive breastfeeding rate increased from 36% at discharge (before the Baby Friendly Hospital Initiative) to 54.7% (after BFHI). The independent risk factors associated with non-exclusive breastfeeding were the use of enteral feeding (OR = 3.01), ante-natal consultations < 6 (OR = 2.75), re lactation use (OR = 2.66), birth weight < 2,500 g (OR = 2.64) and being born during the period before Baby Friendly policies were implemented (OR = 2.75"]
["Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis","Acta Paediatrica","Bireshwar, Sinha, Chowdhury Ranadip, M. J. Sankar, J. Martines, Taneja Sunita, Mazumder Sarmila, N. Rollins, R. Bahl, and Bhandari Nita. “Interventions to Improve Breastfeeding Outcomes: A Systematic Review and Meta-Analysis.” Special Issue: Impact of Breastfeeding on Maternal and Child Health. 104, no. s467 (2015): 114–35.",2015,"Multiple countries","Hospital & Community","Steps 4, 6 and 10","Health workers and postpartum women","To provide comprehensive evidence of the effect of interventions on early initiation,\nexclusive, continued and any breastfeeding rates when delivered in five settings: (i) Health\nsystems and services (ii) Home and family environment (iii) Community environment (iv)\nWork environment (v) Policy environment or a combination of any of above.","Greatest improvements in breastfeeding seen when counseling or education were provided concurrently in various settings.\n \nBaby friendly hospital support at health system was the most effective intervention to improve rates of any breastfeeding.\n\nQuestion remain: To what extent can interventions promote optimal breastfeeding in premature babies and NICU infants.\n\nTo what extent can work place interventions improve exclusive and continued breastfeeding rates.\nRole of educating family or society to promote optimal breastfeeding.\n\nTo promote breastfeeding, interventions should be delivered in a combination of settings by involving health systems, home and family and the community environment\nconcurrently."]
["The baby-friendly hospital initiative and breastfeeding at birth in Brazil: a crosssectional study","Reproductive Health","Boccolini, Siqueira Cristiano, Couto Maria Ines de Oliveira, Lazaro Marcia de Carvalho, and Maria do Carmo Leal. “THE BABY-FRIENDLY HOSPITAL INITIATIVE AND BREASTFEEDING AT BIRTH IN BRAZIL: A CROSS SECTIONAL STUDY.” Annals of Nutrition and Metabolism 71 (2017): 509–509.",2016,"Brazil","Hospital","BHFI overall/all steps ","Newborns and Postpartum women ","To analyze the association between delivery in a BFH (main exposure), compared to non BFH, and timely initiation of breastfeeding (outcome) [BFHI step 4]","Among all births, 40 % occurred in hospitals accredited or in accreditation process for the BFHI and 52 % of women underwent caesarean section. In the final model, at the distal level, mothers less than 35 years old, and those who lived in the North Region, had a higher chance of timely initiation of breastfeeding. At the intermediate level, prenatal care in the public sector and advice on breastfeeding during pregnancy were directly associated with the outcome. At the proximal level, being born in a Baby-Friendly Hospital and vaginal delivery increased the chance of timely initiation of breastfeeding, while prematurity and low birth weight reduced the chance of the outcome. Barriers: Low birth weight and premature babies had lower odds of being breastfed in the first hour after birth"]
["The effect of baby friendly hospital initiative and postnatal support on breastfeeding ratesâ€“Croatian experience","Collegium antropologicum","Bosnjak, A. P., M. Batinica, M. Hegedus-Jungvirth, J. Grguric, and J. Bozikov. “The Effect of Baby Friendly Hospital Initiative and Postnatal Support on Breastfeeding Rates - Croatian Experience.” Collegium Antropologicum 28, no. 1 (2004): 235–43.",2004,"Croatia","Hospital & Community","BHFI overall/all steps ","Newborns and Postpartum women","The aim of our study was  to  explore  the  influence  of  hospital practice and postnatal support on breast feeding rates","Breast feeding rates increased following implementation of BFHI and community based post natal breastfeeding support with the latter having great impact on the breastfeeding rate.\n\nPostnatal care guidelines should have a provision of linking mothers to breastfeeding community groups."]
["Mothersâ€™ expectations and other factors affecting\nbreastfeeding at six months in Greece","Journal of child health care","Bouras, G., P. Mexi-Bourna, N. Bournas, C. Christodoulou, A. Daskalaki, I. Tasiopoulou, and A. Poulios. “Mothers’ Expectations and Other Factors Affecting Breastfeeding at Six Months in Greece.” J Child Health Care 17, no. 4 (2013): 387–96. https://doi.org/10.1177/1367493512468358.",2013,"Greece","Hospital","BHFI overall/all steps ","Postpartum women","To determine the factors influencing breastfeeding duration in Greece.","Baby-friendly hospital, antenatal courses, mother's perception of her capability to successfully breastfeed her infant, mother's intention to breastfeed for a duration of six months or more, mother's and father's education level, introduction of complementary foods or fluids, caesarean delivery, smoking and ethnicity were significantly associated with the duration of breastfeeding. "]
["Braun, M.L.G., Giugliani, E.R., Soares, M.E.M., Giugliani, C., de Oliveira, A.P. and Danelon, C.M.M., ","American Journal of Public Health","Braun, M. L., E. R. Giugliani, M. E. Soares, C. Giugliani, A. P. de Oliveira, and C. M. Danelon. “Evaluation of the Impact of the Baby-Friendly Hospital Initiative on Rates of Breastfeeding.” Am J Public Health 93, no. 8 (2003): 1277–79. https://doi.org/10.2105/ajph.93.8.1277.",2003,"Brazil","Hospital & Community","BHFI overall/all steps ","Postpartum women","To evaluate the impact of the baby-friendly hospital initiative on rates breastfeeding, this before-and-after observational study prospectively followed 2 cohorts of babies born at Hospital de Clínicas de Porto Alegre, Brazil, a general university hospital responsible for approximately 4000 births per year. Most of the population served by the hospital comes from a low socioeconomic stratum.","The present study shows a significant increase in breastfeeding and exclusive breastfeeding rates after BFHI implementation. Of note, the effects of BFHI were stronger in the underprivileged population. The benefits of breast milk are known to be greater in populations at lower socioeconomic levels.4 Despite the occurrence of an increase in breastfeeding rates after BFHI implementation, the frequencies of breastfeeding in the first 6 months of life, especially those of exclusive breastfeeding, are still low. The BFHI in itself appears not to be sufficient to maintain high rates of breastfeeding and exclusive breastfeeding over this period. Interventions made only at 1 moment (such as in the maternity ward) and based solely in hospitals may increase the rates but will have only a short-term effect unless complementary strategies are incorporated.5 Within the BFHI itself, it is possible to obtain more sustainable results through the strengthening of step 10, which seeks the establishment of support groups for mothers who breastfeed after discharge from the maternity ward. As this study evaluated breastfeeding rates in 2 different periods, it is not possible to conclude that BFHI caused an increase in rates. "]
["A realistic evaluation of two training programs on implementing skin-to-skin as a standard of care."," J Perinat Educ","Brimdyr, K., A. M. Widström, K. Cadwell, K. Svensson, and C. Turner-Maffei. “A Realistic Evaluation of Two Training Programs on Implementing Skin-to-Skin as a Standard of Care.” J Perinat Educ 21, no. 3 (2012): 149–57. https://doi.org/10.1891/1058-1243.21.3.149.",2012,"Egypt","Hospital","Step 4","Health workers","To examine  the  real-world  effectiveness  of  two  5-day  training  techniques on sustained optimal skin-to-skin practices that support Step 4 of the revised Baby-Friendly Hospital Initiative  (BFHI).   ","Exposure to the 5-day immersion model (Practice, Reflection, Education and training, Combined with Ethnography for Sustainable Success, or PRECESS) alone or combined with education was an effective strategy to change and sustain the standard of care for skin-to-skin practice. Barriers include: 1. Mothers are not able to see the baby when skin-to-skin.\n2. Mother in pain during episiotomy repair\n3. Exposure of mothers' breasts during skin-to-skin is a problem for modest women\n4. Space and time as staff or delivery area are needed for other births\n5. Distressed baby/mother "]
["The Baby Friendly Hospital Initiative and breast feeding rates in Scotland","Arch Dis Child Fetal Neonatal Ed","Broadfoot, M., J. Britten, D. Tappin, and J. MacKenzie. “The Baby Friendly Hospital Initiative and Breast Feeding Rates in Scotland.” Archives of Disease in Childhood-Fetal and Neonatal Edition 90, no. 2 (2005): 114–16. https://doi.org/10.1136/adc.2003.041558.",2005,"UK","Hospital","BHFI overall/all steps ","Health workers","Objective: To examine the effect of the Baby Friendly Hospital Initiative on breast feeding rates in Scotland. Design: Observational study using an annual survey of progress towards the WHO/UNICEF Baby Friendly Hospital Initiative and routinely collected breast feeding rates gathered on the Guthrie Inborn Errors Screening card at 7 days of postnatal age.","Results: Babies born in a hospital with the UK Baby Friendly Hospital Initiative standard award were 28% (p , 0.001) more likely to be exclusively breast fed at 7 days of postnatal age than those born in other maternity units after adjustment for mother’s age, deprivation, hospital size, and year of birth. From 1995, breast feeding rates had increased significantly faster in hospitals with Baby Friendly status by 2002: 11.39% (95% confidence interval 10.35 to 12.43) v 7.97% (95% confidence interval 7.21 to 8.73). Conclusion: Being born in a hospital that held the award increased the chance of being breast fed. All maternity units should be encouraged to undertake the significant strategic and practical changes required to achieve UK Baby Friendly Hospital Initiative standard status."]
[" Baby-friendly hospital accreditation, in-hospital care practices, and breastfeeding. "," Pediatrics","Brodribb, W., S. Kruske, and Y. D. Miller. “Baby-Friendly Hospital Accreditation, in-Hospital Care Practices, and Breastfeeding.” Pediatrics 131, no. 4 (2013): 685–92. https://doi.org/10.1542/peds.2012-2556.",2013,"Australia","Hospital","BHFI overall/all steps ","Postpartum women","OBJECTIVES: To investigate the effect of Baby-Friendly Hospital Initiative (BFHI) accreditation and hospital care practices on breastfeeding rates at 1 and 4 months. METHODS: All women who birthed in Queensland, Australia, from February 1 to May 31, 2010, received a survey 4 months postpartum. Maternal, infant, and hospital characteristics; pregnancy and birth complications; and infant feeding outcomes were measured.","RESULTS: Sample size was 6752 women. Breastfeeding initiation rates were high (96%) and similar in BFHI-accredited and nonaccredited hospitals. After adjustment for significant maternal, infant, clinical, and hospital variables, women who birthed in BFHI-accredited hospitals had significantly lower odds of breastfeeding at 1 month (adjusted odds ratio 0.72, 95% confidence interval 0.58–0.90) than those who birthed in non–BFHI-accredited hospitals. BFHI accreditation did not affect the odds of breastfeeding at 4 months or exclusive breastfeeding at 1 or 4 months. Four in-hospital practices (early skin-to-skin contact, attempted breastfeeding within the first hour, rooming-in, and no inhospital supplementation) were experienced by 70% to 80% of mothers, with 50.3% experiencing all 4. Women who experienced all 4 hospital practices had higher odds of breastfeeding at 1 month (adjusted odds ratio 2.20, 95% confidence interval 1.78–2.71) and 4 months (adjusted odds ratio 2.93, 95% confidence interval 2.40–3.60) than women who experienced fewer than 4. CONCLUSIONS: When breastfeeding-initiation rates are high and evidence-based practices that support breastfeeding are common within the hospital environment, BFHI accreditation per se has little effect on both exclusive or any breastfeeding rates"]
["Achieving Baby-Friendly Designation at a Large Metropolitan Center. "," American journal of perinatology","Bruney, T., D. Campbell, and A. Iyare. “Achieving Baby-Friendly Designation at a Large Metropolitan Center.” Am J Perinatol 37, no. 4 (2020): 430–35. https://doi.org/10.1055/s-0039-1681056.",2020,"United States","Hospital","Becoming BFHI","Health facility and post-partum women","To describe the journey of obtaining Baby-Friendly designation as a large metropolitan center in an urban city and review the initial patient-related outcomes.","Objective: To describe the journey of obtaining Baby-Friendly designation as a large metropolitan center in an urban city and review the initial patient-related outcomes. Study Design Our medical center participated in the New York City Department of Health and Mental Hygiene Breastfeeding Hospital Collaborative from 2012 to 2017. Monthly meetings were held to monitor data, and audits conducted among prenatal sites and maternity units. This hospital collaborative was established to help facilities through the designation process. Result Breastfeeding education in the prenatal setting was provided consistently at all outpatient sites. By 2017, 89.8% of patients had received appropriate education and support during their prenatal visits. There was a shift in feeding pattern from mostly formula feeding with some breastfeeding to primarily breastfeeding with fewer formula feeds. Baby-Friendly designation was achieved in June 2017 after a formal Baby-Friendly USA assessment. Conclusion Since embarking on this journey, there has been a consistent increase in antenatal patient education and a paradigm shift from some breastfeeding to mostly breastfeeding among the mother–baby dyads which combination feed. Our hospital center has continued to successfully maintain the workflow changes implemented during the Baby-Friendly process."]
["Perspectives of Nurses in Mississippi on Implementation of the Baby-Friendly Hospital Initiative","JOGNN","Burnham, L., A. Gambari, P. Beliveau, J. Ustianov, M. G. Parker, and A. Merewood. “Perspectives of Nurses in Mississippi on Implementation of the Baby-Friendly Hospital Initiative.” J Obstet Gynecol Neonatal Nurs 50, no. 4 (2021): 392–401. https://doi.org/10.1016/j.jogn.2021.02.010.",2021,"United States","Hospital","BHFI overall/all steps ","Health workers","To describe the experiences and perceptions of Mississippi maternity nurses in hospitals that gained Baby-Friendly designation, including perceived barriers and facilitators to implementation of the Baby-Friendly Hospital Initiative","Five main themes:The Change Required for BFHI Was Hard, Nurses Felt Empowered byTaking Leadership Roles, Patient Education Was Pivotal to Practice Implementation, Nurses Felt Challenged by Unintended Consequences, and Attitudes Changed From Negative to Positive Over the Course of Adoption. Barriers include: Nurses were the main drivers of Baby-Friendly adoption and often described the process as difficult or challenging. Participants gave examples of things that could have gone better, including poor communication and the challenge of collaborating across departments. At the same time, they described successful strategies for implementation, including strong nursing leadership, effective delegation of tasks, and suf-ficient patient education. Often, when a hospitalattempts to gain Baby-Friendly designation, itsstaff sees each barrier and roadblock as some-thing that is unique to their local situation. However, we found many similarities among hospitals. Facilities that are currently in the process ofadopting Baby-Friendly processes or plan toengage in this process may gain perspective andease the burden of implementation by learning about the experiences of others. \nDuring our focus groups, participants describedsafety issues and concerns they had before andafter Baby-Friendly designation was obtained.Baby-Friendly USA strongly emphasizes the safe implementation of the Ten Steps and focuses onthree practices in particular: supplementation,rooming-in, and skin-to-skin care (Baby-FriendlyUSA, 2021). The participants in our focus groupsshared concerns related to those practices aswell. It should be noted that many of these concerns, such as the risk of women dropping new-borns or falling asleep with newborns in the bed while breastfeeding, would likely have been pre-sent before beginning the BFHI process. As hospitals continue to adopt the BFHI, it is essential that these safety concerns be addressed up frontand that patient safety is protected and promoted. Participants described the overall process ofBaby-Friendly designation as challenging andcited negative attitudes, misinformation, lack ofcommunication,  and  physician  and  staffresistance as common barriers."]
["UNICEF UK Baby Friendly Initiative: Providing, receiving and leading infant feeding care in a hospital maternity settingâ€”A critical ethnography","Maternal and child health nutrition","Byrom, Anna, Gill Thomson, Mark Dooris, and Fiona Dykes. “UNICEF UK Baby Friendly Initiative: Providing, Receiving and Leading Infant Feeding Care in a Hospital Maternity Setting—A Critical Ethnography.” Maternal & Child Nutrition 17, no. 2 (2021): 1–19. https://doi.org/10.1111/mcn.13114.",2020,"UK","Hospital","BHFI overall/all steps ","Health workers and postpartum women","To explore the influence of the national UNICEF UK BabyFriendly 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.","The findings discussed in this paper highlight how the BFI offers 'informational' (comprehensible), 'practical' (manageable) and 'emotional' (meaningful) support for both staff and service users, strengthened by effective, local leadership and a team approach. This is juxtaposed against the tensions and demands of the busy 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. Barriers include: Time constraints and the competing demands of the wider mater-nity service-imposed threats to staff manageability, especially the midwives. "]
["The effect of the baby-friendly hospital initiative\non long-term breast feeding","International journal of clinical practice","Camurdan, A. Duyan, S. Oezkan, D. Yueksel, F. Pasli, F. Sahin, and U. Beyazova. “The Effect of the Baby-Friendly Hospital Initiative on Long-Term Breast Feeding.” International Journal of Clinical Practice 61, no. 8 (2007): 1251–55. https://doi.org/10.1111/j.1742-1241.2007.00926.x",2007,"Turkey","Hospital","BHFI overall/all steps ","Newborns ","The  aim  of  this  study  was  to  evaluate  the  effects  of 'baby-friendly  hospital  initiative'  (BFHI)  on  breast  feeding.","BFHI increased the duration of breast feeding by 1.5 times. In addition to increased breast feeding rates in the first 6 months, BFHI supported prolonged duration of breast feeding (more than 12 months)"]
["\nThe baby-friendly hospital initiative and\nbreastfeeding at birth in Brazil: a cross\nsectional study","Reproductive Health","Carvalho, M. L., C. S. Boccolini, M. I. Oliveira, and M. D. Leal. “The Baby-Friendly Hospital Initiative and Breastfeeding at Birth in Brazil: A Cross Sectional Study.” Reprod Health 13, no. Suppl 3 (2016): 119. https://doi.org/10.1186/s12978-016-0234-9.",2016,"Brazil","Hospital","BHFI overall/all steps ","Newborns and postpartum women","The aim of this study was to analyze the association between delivery in a BFH (main exposure), compared to non BFH, and timely initiation of breastfeeding (outcome)","The chance of being breastfed in the first hour after birth in Baby-Friendly hospitals was twice as high as at non-accredited hospitals. Additionally  prenatal care in the public sector and advice on breastfeeding during pregnancy were directly were associated with the outcome."]
[" Protection, promotion and support of breast-feeding in Europe: current situation. ","Public health nutrition","Cattaneo, A., A. Yngve, B. Koletzko, and L. R. Guzman. “Protection, Promotion and Support of Breast-Feeding in Europe: Current Situation.” Public Health Nutr 8, no. 1 (2005): 39–46. https://doi.org/10.1079/phn2005660.",2005,"EU member states","Country-level comparison","BHFI overall/all steps ","Key informants: Breastfeeding coordinators and breastfeeding committes","To describe the current situation regarding protection, promotion and support of breast-feeding in Europe, as a first step towards the development of a blueprint for action","Results: EU countries do not fully comply with the policies and recommendations of the Global Strategy on Infant and Young Child Feeding that they endorsed during the 55th World Health Assembly in 2002. Some countries do not even comply with the targets of the Innocenti Declaration (1990). Pre-service training on breast-feeding practice is inadequate and in-service training achieves only low to medium coverage. The Baby Friendly Hospital Initiative is well developed only in three countries; in 19 countries, less than 15% of births occur in baby-friendly hospitals. The International Code of Marketing of Breastmilk Substitutes, endorsed in 1981 by all countries, is not fully applied and submitted to independent monitoring. The legislation for working mothers meets on average the International Labour Organization standards, but covers only women with full formal employment. Voluntary mother-to-mother support groups and trained peer counsellors are present in 27 and 13 countries, respectively. Breast-feeding rates span over a wide range; comparisons are difficult due to use of non-standard methods. The rate of exclusive breast-feeding at 6 months is low everywhere, even in countries with high initiation rates. Conclusions: EU countries need to revise their policies and practices to meet the principles inscribed in the Global Strategy on Infant and Young Child Feeding in order to better protect, promote and support breast-feeding."]
["Effect on rates of breast feeding of training for the baby friendly hospital initiative","BMJ","Cattaneo, A., and R. Buzzetti. “Quality Improvement Report: Effect on Rates of Breast Feeding of Training for the Baby Friendly Hospital Initiative.” British Medical Journal (Clinical Research Edition) 323, no. 7325 (2001): 1358–62. https://doi.org/10.1136/bmj.323.7325.1358.",2001,"Italy","Hospital","BHFI overall/all steps ","Health workers and postpartum women and their babies ","To examine the effects of the Unicef course on\nhospital  practices, knowledge  of  health  workers, and breastfeeding  rates  at  discharge  and  three  and  six months later in a high income country","Strategies for change :\nTraining of trainers and subsequent training of health workers with a slightly adapted version of the 18 hour Unicef course on breastfeeding management and promotion. Key measures for improvement Hospital practices, knowledge of 571 health workers, and breastfeeding rates at discharge, three, and six months in 2669 mother and baby pairs.\nEffects of change: After training hospitals improved their compliance with the “ten steps to successful breast feeding,” from an average of 2.4 steps at phase one to 7.7 at phase three. Knowledge scores of health professionals increased from 0.41 to 0.72 in group 1 (training after phase one) and from 0.53 to 0.75 in group 2 (after phase two). The rate of exclusive breast feeding at discharge increased significantly after training: 41% to 77% in group 1 and 23% to 73% in group 2, as did the rates of full (exclusive plus predominant) breast feeding at three months (37% to 50% in group 1 v 40% to 59% in group 2) and any breast feeding at six months (43% to 62% in group 1 v 41% to 64%in group 2). \nLessons learnt: Training for at least three days with a course including practical sessions and counselling skills is effective in changing hospital practices, knowledge of health workers, and breastfeeding rates."]
[" Effectiveness of the Baby Friendly Community Initiative in Italy: a non-randomised controlled study. ","BMJ","Cattaneo, A., M. E. Bettinelli, E. Chapin, A. Macaluso, L. Cordova Do Espirito Santo, A. M. Murante, and M. Montico. “Effectiveness of the Baby Friendly Community Initiative in Italy: A Non-Randomised Controlled Study.” BMJ Open 6, no. 5) (2016). https://doi.org/10.1136/bmjopen-2015-010232.",2016,"Italy","Community ","BFCI only  ","Newborns and postpartum women","To assess the effectiveness of the Baby Friendly Community Initiative (BFCI) on exclusive\nbreast feeding at 6 months","Results: The crude rates of exclusive breast feeding at discharge, 3 and 6 months, and of any breast feeding at 6 and 12 months increased at each round of data collection after baseline in the early and late intervention groups. At the end of the project, 10% of infants were exclusively breast fed at 6 months and 38% were continuing to breast feed at 12 months. However, the comparison by adjusted rates and logistic regression failed to show statistically significant differences between groups and rounds of data collection in the intention-to-treat analysis, as well as when compliance with the intervention and training coverage was taken into account. Conclusions: The study failed to demonstrate an effect of the BFCI on the rates of breast feeding. This may be due, among other factors, to the time needed to observe an effect on breast feeding following this complex intervention."]
["Baby-friendly hospitals in Turkey: evaluation of adherence to the Ten Steps to Successful Breastfeeding. ","East Mediterr Health J. ","Caylan, N., M. Kilic, S. Yalcin, B. Tezel, and F. Kara. “Baby-Friendly Hospitals in Turkey: Evaluation of Adherence to the Ten Steps to Successful Breastfeeding.” Eastern Mediterranean Health Journal 28, no. 5 (2022): 352–61. https://doi.org/10.26719/emhj.22.021.",2022,"Turkey","Hospital","BHFI overall/all steps ","Hospital","To analyse the 2018-2019 external reassessment results of baby-friendly hospitals (BFHs) in Turkey","All 10 steps were fulfilled by 60.1% of the hospitals.  Steps 3 and 2 had the lowest compliance rates (81.6% and 85.7%), and Steps 7 and 8 had the highest rates (97.1% and 98.1%). Caesarean section rates in the fourth quartile were asso-ciated with significantly lower adherence to Steps 3 and 10. The presence of another external reassessment within 5 years was associated with a significantly higher adherence rate to Step 3, and a significantly higher full implementation rate for the clinical practices. Hospitals that fully implemented management procedures had a significantly higher fulfilment percentage for all clinical practices. The western region had higher adherence rates for all the clinical practices than other regions."]
["Factors influencing the intention of perinatal nurses to adopt the Baby - Friendly Hospital Initiative in Southeastern Quebec, Canada: implications for practice","Nursing Research and Practice","Chabot, G., and M. Lacombe. “Factors Influencing the Intention of Perinatal Nurses to Adopt the Baby-Friendly Hospital Initiative in Southeastern Quebec, Canada: Implications for Practice.” Nurs Res Pract 2014 (2014): 603964. https://doi.org/10.1155/2014/603964.",2014,"Canada","Hospital","Step 3 - 10","Health workers","To identify the factors influencing perinatal nurses to adopt the BFHI in their practice","Participants are mainly influenced by:\nFactors pertaining to their perceived capacity to overcome the strict criteria of the BFHI;\nThe mother's approval of a nursing practice based on the BFHI; \nThe antenatal preparation of the mothers.\n\nThere is need to understand the relationships of organizational measures such as the implementation of steps 1 and 2 on nurses' intention to adopt the BFHI and their related professional practices."]
["Breastfeeding rates and hospital breastfeeding practices in Canada: A national survey of women","BIRTH","Chalmers, B., C. Levitt, M. Heaman, B. O’Brien, R. Sauve, and J. Kaczorowski. “Breastfeeding Rates and Hospital Breastfeeding Practices in Canada: A National Survey of Women.” Birth 36, no. 2 (2009): 122–32. https://doi.org/10.1111/j.1523-536X.2009.00309.x.",2009,"Canada","Community ","BHFI overall/all steps ","Postpartum women","To report breastfeeding rates and adherence to the Baby Friendly Hospital Initiative of the World Health Organisation and UNICEF in Canada","High breastfeeding intention and initiation rates; Exclusive Breastfeeding rates at 6 months    lower than desirable; Low adherence to several best practices advocated by the BFHI. \n\nSome aspects of care could not be specified as it was uncertain if participants could have knowledge about them e.g availability of a breastfeeding policy at the hospital."]
["Feeding practices of infants delivered in a district hospital during the implementation of Baby Friendly Hospital Initiative","Med J Malaysia","Chan, S. K., and C. V. Asirvatham. “Feeding Practices of Infants Delivered in a District Hospital during the Implementation of Baby Friendly Hospital Initiative.” Med J Malaysia 56, no. 1 (2001): 71–76.",2001,"Malaysia","Hospital & Community","Becoming/pre BFHI","Newborns ","To find out the feeding practices of infants delivered in Hospital Seri Manjung (HSM),  to identify the population subgroups that had lower breastfeeding rates at 4 months and the effect of attendance of antenatal breastfeeding eductaion on breastfeeding practices.","This study showed that BF rates at 4 months were subobtimal in Chinese working mothers. Ante-natal education appeared to improve BF at 4 months. Exclusive breastfeeding rates were higher, antenatal breastfeeding education improved breastfeeding rates at 4 months. "]
["Knowledge and attitude regarding breastfeeding in mothers attending antenatal clinics","Indian J Pediatr","Chaturvedi, P., and N. Banait. “Knowledge and Attitude Regarding Breast-Feeding, in Mothers Attending Antenatal Clinics.” Indian J Pediatr 67, no. 4 (2000): 259–62. https://doi.org/10.1007/bf02758164.",1993,"India","Hospital","BHFI overall/all steps ","Postpartum women","To assess knowledge and attitude of postpartum mothers who attended antenatal clinics of a Baby Friendly Hospital regarding breastfeeding","Only 54.5% of mothers who had attended antenatal care at the facility and 30.3% of those who did not attend antenatal care at the facility were informed about breastfeeding benefits at the antenatal. \nThe mothers who attended antenatal care at the facility initiated breastfeeding early and did not want to give additional food as compared to those who did not .\n\nDespite training the obstetricians in BFHI, nearly half of the women did not get information regarding benefits of breastfeeding. Every antenatal contact must be fully utilized to impact knowledge on breastfeeding to the women."]
["A review of breastfeeding practices in  Hong Kong","N/A","Chee, Y. O., and L. Horstmanshof. “A Review of Breastfeeding Practices in Hong Kong -- 1994/1995.” Breastfeeding Review 4, no. 1 (1996): 7–12.",1993,"China","Hospital","BHFI overall/all steps ","Postpartum women","To examine the degree to which the HOng Kong hospitals adhered to the ten steps and also the extent to which mothers perceived themselves supported to breastfeed on postnatal day","There have been improvements in the hospital practices that encourage breastfeeding, but there is still much work to be done to empower mothers to breastfeed in Hong Kong"]
["Baby-friendly hospital initiative accreditation in Taiwan: Challenges and assistance needs","Midwifery","Chen, Li-Li, Meei-Ling Gau, Chien-Huei Kao, and Wan-Lin Pan. “Baby-Friendly Hospital Initiative Accreditation in Taiwan: Challenges and Assistance Needs.” Midwifery 94 (2021): N.PAG-N.PAG. https://doi.org/10.1016/j.midw.2020.102903.",2021,"Taiwan","Hospital","Becoming/pre BFHI","Health workers","A sample comprising administrators and maternity and pediatric department managers\nworking at non-BFI facilities in Taiwan was interviewed to explore the difficulties encountered and assistance required with regard to implementing Ten 'Steps to Successful Breastfeeding' policies.","Barriers: This study found that many challenges impacted the implementation of BFI policies. These challenges may be distinguished into three categories: institutional (human resources, cost, and facility layout), personal (attitudes/beliefs and knowledge about breastfeeding), and sociocultural factors (formula marketing and Chinese culture). \n\nIn this study, the primary challenges faced by medical facilities in applying for BFI accreditation were: 1) the ambivalence and passivity of medical facility managers toward accreditation, 2) differences in BFI promotion enthusiasm among medical personnel, 3) the impact of Chinese culture and formula marketing efforts on the social environment, and 4) disincentives / barriers to taking desired actions"]
["The number of Baby Friendly hospital practices experienced by mothers is positively associated with breastfeeding: A questionnaire survey","International Journal of Nursing Studies","Chien, L. Y., C. J. Tai, K. H. Chu, Y. L. Ko, and Y. C. Chiu. “The Number of Baby Friendly Hospital Practices Experienced by Mothers Is Positively Associated with Breastfeeding: A Questionnaire Survey.” Int J Nurs Stud 44, no. 7 (2007): 1138–46. https://doi.org/10.1016/j.ijnurstu.2006.05.015.",2007,"Taiwan","Hospital & Community","BHFI overall/all steps ","Postpartum women","To examine the association between number of Baby Friendly hospital practices experienced by mothers and breastfeeding initiation during hospital stay, breastfeeding at 1 month and breastfeeding at 3 months after delivery","Only 1% of women experienced all ten steps, 5.7% did not experience any baby friendly practices, mothers who delivered at certified baby friendly hospitals experienced more 10 step practices.\n\nThere is need for greater attention to implement the 10 steps."]
["Study of infant feeding practices: factors associated with faulty feeding","Journal of Tropical Pediatrics","Chintan, Parekh, S. B. Bavdekar, and V. Shaharao. “Study of Infant Feeding Practices: Factors Associated with Faulty Feeding.” Journal of Tropical Pediatrics 50, no. 5 (2004): 306–8. https://doi.org/10.1093/tropej/50.5.306.",2004,"India","Hospital","BHFI overall/all steps ","Postpartum women","KEM Hospital, Mumbai was recognized as a ‘baby-friendly’ hospital on the basis of adherence to the ‘Ten steps to successful breastfeeding’, a decade ago. This study was undertaken to determine the sustainability of the programme in terms of feeding practices undertaken by the mothers on the basis of advice given to them.","A total of 92.11 per cent of the infants up to 6 months of age received exclusive breastfeeding. Timely complementary feeding rate was 95 per cent. Thus interventions used in the programme seem sustainable.\n\nThe advice regarding infant feeding practices given in the immediate postnatal period and subsequent visits to the well-baby clinic are effective. Mothers should receive information regarding proper infant feeding practices during the antenatal period, the immediate postnatal period, and during visits to the well-baby clinic. It should be ensured that mothers understand the rationale of the practices that are being advised so that good feeding practices are sustained. Mothers need to be told that commercial weaning foods do not confer any advantages over less expensive supplements."]
["Effects of a â€˜Baby-Friendly Hospital Initiativeâ€™ on exclusive breastfeeding rates at a private hospital in Lebanon: an interrupted time series analysis","BMC Pregnancy and Childbirth","Clermont, A., J. E. Gemayel, R. Hammoud, J. Wang, H. Beciu, M. Sinno, W. Berends, et al. “Effects of a ‘Baby-Friendly Hospital Initiative’ on Exclusive Breastfeeding Rates at a Private Hospital in Lebanon: An Interrupted Time Series Analysis.” BMC Pregnancy Childbirth 21, no. 1 (2021): 385. https://doi.org/10.1186/s12884-021-03816-3.",2021,"Lebanon","Hospital","BHFI overall/all steps ","Newborns and postpartum women","This study documents the implementation of BFHI at Clemenceau Medical Center (CMC), a private hospital in Lebanon, and analyzes data on EBF practices among CMC's patients before, during, and after the implementation period. ","The steps necessary to bring CMC in line with the BFHI standards were implemented during the periodbetween November 2015 and February 2016. These steps can be grouped into three phases: updates to hospital policies and infrastructure (Phase 1); changes to healthcare staff practices (Phase 2); and improvements in patient education (Phase 3). The baseline percentage of EBF was 2.4 % of all live births. Following the BFHI intervention, theobserved monthly change in EBF in the 'Follow-Up' period (i.e., the 24 months following Phases 1-3) was significantly increased relative to the baseline period (+ 2.0 % points per month, p= 0.006). Overall, the observed rate of EBF at hospital discharge increased from 2.4 to 49.0 % of all live births from the first to the final month of recorded data.                                                                                             Barriers: Several challenges arose during BFHI implementation,many of which reflect cultural barriers to breastfeeding that persist in Lebanon. For practices such as skin-to-skin contact after birth, adoption of such practices bywomen occurred quickly, demonstrating that successful behavior change is possible. However, many CMC pa-tients, family members, and even occasionally outpatient healthcare providers still expressed doubt that breast-milk  is  nutritionally  sufficient  for  newborns.  Somemothers also resisted the rooming-in policy, expressing the need to rest while their infant is cared for in a nur-sery. \n\nAnother challenge in implementing this initiative is re-flective of the fact that CMC employs a combination offull-time clinicians in addition to part-time providersfrom the community. For those part-time providers(who primarily practice outside the hospital but bringtheir patients to CMC for delivery), it has been more dif-ficult to become engaged in the Phase 2 activities aimedat changing clinical practices, and accordingly, EBFadoption has been slower in this group. Further targetedoutreach to these providers is planned."]
["Education on antenatal colostrum expression and the baby friendly Health initiative in Australian hospital: an audit of birth and breastfeeding outcomes","Research","Connolly, Emma L., Misty Reinkowsky, Roslyn Giglia, Belinda Sexton, Philippa Lyons-Wall, Johnny Lo, and Therese A. O’Sullivan. “Education on Antenatal Colostrum Expression and the Baby Friendly Health Initiative in an Australian Hospital: An Audit of Birth and Breastfeeding Outcomes.” Breastfeeding Review 27, no. 1 (2019): 21–30.",2019,"Australia","Hospital","BHFI overall/all steps ","Prenatal women","To assess breastfeeding and birth outcomes before and after provision of antenatal colostrum expression (ACE) education and BFHI care as standard hospital practice.","Mothers were more likely to see a lactation consultant after introduction of ACE education (p=0.045) and with BFHI care (p=0.053), increased initiation of breastfeeding (p=0.049), ACE education was not associated with significantly increased rates of special care nursery admission or lower gestational age at birth"]
["Overcoming rooming-in barriers: a survey on mothers, perspectives.","Frontiers in Pediatrics","Consales, A., B. L. Crippa, J. Cerasani, D. Morniroli, M. Damonte, M. E. Bettinelli, D. Consonni, et al. “Overcoming Rooming-In Barriers: A Survey on Mothers’ Perspectives.” Front Pediatr 8 (2020): 53. https://doi.org/10.3389/fped.2020.00053.",2020,"Italy","Hospital","Step 7","Newborns and postpartum women","To investigate maternal knowledge of rooming-in and the most frequently encountered barriers and possible facilitators of adherence to the practice, according to their experience","Majority of mothers knew of rooming in and  48.2% practiced it continuously. Main reported obstacles were fatigue (40.5%) and caesarean section related difficulties. Night was the most critical time of the day for rooming in. Mothers who adhered to rooming in had a higher exclusive breastfeeding rate at discharge compared to mothers who did not."]
["Successful breastfeeding: A global intervention for a physiological process","Acta bio-medica: Atenel Parmensis","Corona, M. F., P. Cataldi, G. Zaccagnini, S. Maddaluno, V. Capone, A. Conti, D. Carlucci, S. Silvano, A. Bertone, and S. Parmigiani. “Successful Breastfeeding: A Global Intervention for a Physiological Process.” Acta Biomed 87, no. 2 (2016): 156–60.",2016,"Italy","Community ","BHFI overall/all steps ","Postpartum women","We here report the results at short and medium term of our perinatal unit after having implemented this intervention: \nFocus: Giving the mother and her baby opportunities that allow a good bonding from the beginning: \nskin-to-skin contact immediately after birth, \nbreast sucking possibly within the 1st hour of life, \nrooming-in, \nregular checks by educated personnel of suction and attachment, \navoidance of any nonjustified supplement of formula milk,\nsupport after HD. \nMother’s self-esteem is important and can be improved both by birthing classes and by support after HD. \nWe here report the results at short and medium term of our perinatal unit after having implemented all the above cited aspects. "," In our perinatal unit we applied the ten steps of WHO/UNICEF for Baby Friendly Hospital Initiative and evaluated the percentage of exclusive (EBF) or complementary breastfeeding (CBF), and of formula fed (FF) healthy full-term infants (HFI) at hospital discharge (HD). HFI performing EBF at HD were 85.3%, a quite high value. At the age of 3 mths EBF percentage ranged between 59-62.4%, and at 6 mths it decreased to 51.7-37.7%. Customer satisfaction questionnaire at HD ranked “good” to “very good” in 92.8%. Causes of breastfeeding reduction with time and comparison with previous and actual situation in Italy and civilized countries are discussed."]
["The impact of training based on the baby friendly hospital initiative on breastfeeding practices in the Northeast of Brazil","Journal de Pediatrica","Coutinho, S. B., M. de C. Lima, A. Ashworth, and P. I. C. Lira. “The Impact of Training Based on the Baby-Friendly Hospital Initiative on Breastfeeding Practices in the Northeast of Brazil.” Jornal de Pediatria 81, no. 6 (2005): 471–77. https://doi.org/10.2223/JPED.1422.",2005,"Brazil","Hospital & Community","Step 4-10","Newborns and postpartum women","To evaluate the impact of training based on the Baby Friendly Hospital Initiative on breastfeeding\npractices in maternity wards and during the first 6 months of life","There was an improvement in breastfeeding practices at the maternity wards and an increase of exclusive breastfeeding prevalence from 21.2 to 70% during the first 48 hours after delivery and throughout the first 6 months.\n\nThere is need for effective interventions to support exclusive breastfeeding in the health sector and in the community"]
["Comparison of the effect of two systems for the promotion of exclusive breastfeed","Lancet","Coutinho, S. B., P. I. de Lira, M. de Carvalho Lima, and A. Ashworth. “Comparison of the Effect of Two Systems for the Promotion of Exclusive Breastfeeding.” Lancet 366, no. 9491 (2005): 1094–1100. https://doi.org/10.1016/s0140-6736(05)67421-1.",2005,"Brazil","Hospital","BHFI overall/all steps ","Postpartum women"," To  compare  the  effects  on  rates  of  breastfeeding  of  two systems for promotion of breastfeeding in Brazil-- a hospital-based system and the same system combined with a\nprogram of home visits","Findings The hospital-training intervention achieved a high rate (70%) of exclusive breastfeeding in the hospitals, but this rate was not sustained at home and at 10 days of age only 30% of infants were exclusively breastfed The patterns of exclusive breastfeeding in the two trial groups for days 10–180 differed significantly (p0·0001), with a mean aggregated prevalence of 45% among the group assigned home visits compared with 13% for the group assigned none. \n\nInterpretation The BFHI achieves high rates of exclusive breastfeeding in hospital; however, in Brazil at least, the rates fall rapidly thereafter. Reliance on the BFHI as a strategy for breastfeeding promotion should be reassessed. A combination of promotional systems (hospital-based and in the community) is needed."]
["Optimizing successful breastfeeding in the newborn","Office Pediatrics","Cramton, R., M. Zain-Ul-Abideen, and B. Whalen. “Optimizing Successful Breastfeeding in the Newborn.” Curr Opin Pediatr 21, no. 3 (2009): 386–96. https://doi.org/10.1097/MOP.0b013e32832b325a.",2009,"United States","Hospital & Community","BHFI overall/all steps ","Newborns and postpartum women","To present an overview of the state of breastfeeding in the United States and to examine recent evidence for strategies aimed at optimizing successful breastfeeding in the neonatal period","BFHI based on the ten steps to successful breastfeeding is an effective evidence based model of perinatal care that protects, promotes and supports breastfeeding.\n\nA significant proportion of pediatricians are not providing evidence based recommendations for breastfeeding guidance and support."]
["Maternity Nurses Perceptions of Implementation Ten Steps to Successful Breastfeeding","American Journal of Maternal and Child Nursing ","Cunningham, E. M., E. I. Doyle, and R. G. Bowden. “Maternity Nurses’ Perceptions of Implementation of the Ten Steps to Successful Breastfeeding.” MCN Am J Matern Child Nurs 43, no. 1 (2018): 38–43. https://doi.org/10.1097/nmc.0000000000000392.",2018,"United States","Hospital","BHFI overall/all steps ","Health workers","To determine maternity nurses' perceptions of implementing the Ten Steps to Successful Breastfeeding ","Results, barriers: Nurse staff shortages:  variations in practice among nurses;  different levels of Nurse education & knowledge about BF; lack of parental awareness & knowledge about BF, culture and postpartum issues such as Maternal fatigue, visitors nad routines required; inconsistencies in practice and philosophies among nurses in how they approach BF support; BF support does not appear to be uniform or systemic and possibly contributes to care disparities; maternity nurses required more education about BF, a hands-on approach rather than formal classroom instruction. \n\nRecommendations: More education on BF for maternity nurses, physicians, new mothers and their familiies, as well as leadership support. \n\nNoted: Perception that 10 Steps implementation limits mothers choices and fosters a rigid hospital environment. Future education about BF for nurses shuold make special effort to clarify these misconceptions with the understanding that the 10 Steps increase success for all mothers using all feeding methods. "]
["Do maternity hospital practices support Greek mothers' decision to breastfeed?","Clinical and experimental obstetrics and gynecology","Daglas, M., V. Petoussi, G. Dionysiou, and I. Athanassakis. “Do Maternity Hospital Practices Support Greek Mothers’ Decision to Breastfeed?” Clin Exp Obstet Gynecol 37, no. 1 (2010): 43–48.",2010,"Greece","Hospital & Community","BHFI overall/all steps ","Newborns and postpartum women","To investigate the degree that Greek maternity hospitals have adopted the \"ten steps to successful breastfeeding","- 40.5% of the mothers did not know what the first meal of their\nbaby was. \n- 68.3% of the mothers mentioned that artificial milk was brought in every meal of the neonate, while 63.6% believed that artificial milk was given to their child without their knowledge, despite the fact that they had already decided to breastfeed.\n - 90% of the mothers giving birth in public maternity hospitals and 60% delivering in private\nclinics mentioned that health professionals supported breastfeeding (p< 0.05). "]
["Knowledge, attitudes and practices of nursing staff regarding the Baby-Friendly Hospital Initiative in non-accredited obstetric units in Cape Town","South African Journal of Clinical Nutrition","Daniels, L., and D. Jackson. “Knowledge, Attitudes and Practices of Nursing Staff Regarding the Baby-Friendly Hospital Initiative in Non-Accredited Obstetric Units in Cape Town.” South African Journal of Clinical Nutrition 24, no. 1 (2011): 32–38. https://doi.org/10.1080/16070658.2011.11734347.",2011,"South Africa","Hospital","Becoming/pre BFHI","Health workers","To assess nursing staff knowledge, attitudes and practices regarding the Baby-Friendly hospital Initiative (BFHI)\nTo assess the knowledge of maternity obstetric unit managers regarding BFHI principles and their attitude towards BFHI                                                                                                                                                                                                                                                           implementation\nTo describe the barriers and constraints to the implementation of BFHI principles","There was acceptable awareness and knowledge of the recommended BFHI principles.\n- the enrolled nursing assistants were significantly less knowledgeable than the other cadres of nurses.\n- the majority of the nurses had a positive attitude toward BFHI principles and practices"]
["Breastfeeding Practices in a Teaching Hospital of Calcutta before and after the Adoption of BFHI","Journal of the Indian Medical Association","Dasgupta, A., S. Bhattacharya, M. Das, K. M. Chowdhury, and S. Saha. “Breast Feeding Practices in a Teaching Hospital of Calcutta before and after the Adoption of BFHI (Baby Friendly Hospital Initiative).” J Indian Med Assoc 95, no. 6 (1997): 169–71, 195.",1993,"India","Hospital","BHFI overall/all steps ","Postpartum women","1. To investigate the BF practices of the newborns in the postnatal wards\n2. To find the impact of the introduction of the BFHI in the hospital on BF practices by before and after comparision studies \n3. To investigate the probelems of mothers not practising exclusive BF and suggest measures of improvement. ","- There is an overall improvement in the time of initiation of BF of c section babies after the adoption of BFHI.\n- Before the adoption of BFHI in the postnatal ward, 46% of babes were given in-between feeds, even after the initiation of BF. In-between feeds reduced to 19.6% after the BFHI was launched. \n- Pre-lacteal feeds were given to 100% of newborns irrespective of the type of delivery before the hospital was Baby Friendly. After the introduction of BFHI, there was significant reduction from 100%-33.3% in normally delivered babies, with no change for C section.  "]
["Cost Comparison of Baby Friendly and Non - Baby Friendly Hospitals in the United States","Pediatrics","DelliFraine, J., J. Langabeer 2nd, J. F. Williams, A. K. Gong, R. I. Delgado, and S. L. Gill. “Cost Comparison of Baby Friendly and Non-Baby Friendly Hospitals in the United States.” Pediatrics 127, no. 4 (2011): e989-94. https://doi.org/10.1542/peds.2010-1591.",2011,"United States","Hospital","BHFI overall/all steps ","Health facility level","To provide economic assessment of the incremental costs associated with obtaining the World Health Organization and United Nations International Children's Emergency Fund designation as an Infant- Friendly hospital.","Baby friendly facilities have slightly higher costs than non baby friendly facilities, ranging from 1.6% to 5%, but these costs were not statistically significant."]
["Cost Comparison of Baby Friendly and Non-Baby Friendly Hospitals in the United States","Pediatrics","DelliFraine, J., J. Langabeer 2nd, R. Delgado, J. F. Williams, and A. Gong. “A Transition Strategy for Becoming a Baby-Friendly Hospital: Exploring the Costs, Benefits, and Challenges.” Breastfeed Med 8 (2013): 170–75. https://doi.org/10.1089/bfm.2012.0050.",2013,"UK","Hospital","BFHI and non-BFHI","Health facility level","The objectives of this study were to provide an economic assessment of the incremental costs associated with obtaining the World Health Organization and United Nations International Children's Emergency Fund designation as a Infant-Friendly hospital. ","- Delivery in Baby-Friendly Hospitals was more expensive in comparison to non-BFHI, at $2,205 vs $2,170. The costs of the facilities were not statistically significant. \n- Becoming Baby-Friendly is suggested to be cost-neutral for typical acute hospital care. "]
["Implementing Legislation to ImproveHospital Support of Breastfeeding, NewYork State, 2009â€“2013","Preventing Chronic Disease ","Dennison, B. A., B. A. Hawke, R. A. Ruberto, and D. J. Gregg. “Implementing Legislation to Improve Hospital Support of Breastfeeding, New York State, 2009-2013.” Prev Chronic Dis 12 (2015): E122. https://doi.org/10.5888/pcd12.150121.",2015,"United States","Hospital","BHFI overall/all steps ","Hospital policies ","To assess hospital policy compliance with New York laws and regulations related to breastfeeding","The number and percentage of hospitals that had a fully compliant hospital breastfeeding policy (total score = 28) in-creased 15-fold during this time period, from 0 in 2009 to 6 (5%)in 2011 to 97 (75%) in 2013\n- The percentage of hospitals with fully compliant policies increased from 0% in 2009, to 5% in 2011, and to 75% in 2013\n-The percentagethat included all WHOâ€™s 10 steps increased from 0% to 9% to87%, respectively "]
["The Impact of Hospital Resources and Availabilityof Professional Lactation Support on Maternity Care: Results of Breastfeeding Surveys 2009â€“2014","Breastfeeding Medicine ","Dennison, B. A., T. Q. Nguyen, D. J. Gregg, W. Fan, and C. Xu. “The Impact of Hospital Resources and Availability of Professional Lactation Support on Maternity Care: Results of Breastfeeding Surveys 2009-2014.” Breastfeed Med 11 (2016): 479–86. https://doi.org/10.1089/bfm.2016.0072.",2016,"United States","Hospital","Steps 1-7, 9-10","Hospital policies","To evaluate changes in New York hospitals in the implementation of recommended maternity care practices, provision of professional lactation support,and reported hospital and patient barriers to breastfeeding support between 2009 and 2014","- Surveys were completed by New York hospitals in 2009, 2011, and 2014.\n- During this time period, the percent of hospitals reporting implementation of Steps 2, 4, 6, or 9 increased.\n- Hospitals distributing formula samples at discharge to breastfeeding mothers decreased significantly from 39 (32%) to 3 (2%). \n- Professional lactation staffing ratios (N/1,000 births) of both International Board Certified Lactation Consultants and Certified Lactation Counselors increased between 2009 and 2011, but then decreased between 2011 and 2014. \n"]
["Effect of Maternity-Care Practices on Breastfeeding","Pediatrics","DiGirolamo, A. M., L. M. Grummer-Strawn, and S. B. Fein. “Effect of Maternity-Care Practices on Breastfeeding.” Pediatrics 122 Suppl 2 (2008): S43-9. https://doi.org/10.1542/peds.2008-1315e.",2008,"United States","Hospital","Step 4, 6-10","Newborns and postpartum women","To  examine  the  current  prevalence  and  the  individual  and  cumulative influences of a greater number of Baby-Friendly hospital practices on breastfeeding duration among mothers who intended to breastfeed for at least 2 months postpartum. \n- Using data from the IFPS II, the study provides an opportunity to assess changes in the prevalence of reported Baby-Friendly\u009d hospital practices since the administration of the original IFPS 11 years ago and to confirmthe cumulative effects of a more complete measurementof these practices on breastfeeding.\n- To  assess  the  impact  of \n additional maternity-care practices not currently designated as being Baby-Friendly on breastfeeding duration","Only 8.1% of the mothers experienced all 6 Baby-Friendly\u009d practices. \n- At least half of the mothers reported experiencing each of the 6 practices. \n- The  overall  prevalence  of  women  who  terminated breastfeeding  by  6  weeks  postpartum  was  14.4%.\n\n- Compared  with  the  mothers  who  experienced  all  6â€œBaby-Friendlyâ€\u009d  practices,  mothers  who  experienced  none  were 13  times more likely to stop breastfeeding early.\n\n The practices  most  consistently  associated  with  breastfeeding  beyond  6  weeks  were initiation within 1 hour of birth, giving only breast milk, and not using pacifiers.\n- Bringing the infant to the room for feeding at night if not rooming in and not giving pain medications to the mother during delivery were also protective against early breastfeeding  termination.  \n- Additional practices decreased the risk for early termination\n\n"]
["Maternity Care Practices: Implications for Breastfeeding","BIRTH ","DiGirolamo, A. M., L. M. Grummer-Strawn, and S. Fein. “Maternity Care Practices: Implications for Breastfeeding.” Birth 28, no. 2 (2001): 94–100. https://doi.org/10.1046/j.1523-536x.2001.00094.x.",2001,"United States","Hospital","BHFI overall/all steps ","Postpartum women","To assess the reported prevalence of selected Baby Friendly practices experienced by mothers throughout the US and to assess the independent and cumulative impact of These practices on BF duration.\n- to assess the number of practices experienced and estimate the relation between number of practices experienced and BF outcome.","Only 7% of mothers experienced all five Baby-Friendly practices. \n- The  cumulative  effect  of  these  practices,  rather  than each individual practice, is most important in breast-feeding outcome\n- Those most influential on BF outcome incldued exclusivity of BF in the hospital and BF initiation within 1hr of birth. \n\n- The strongest risk factors for early breastfeeding termination were late BF initiation and supplementing the infant.\n- Compared with mothers experiencing all five Baby-Friendly practices (hospital formula use, rooming-in, forumula or coupons for forumla in gift pack, hospital pacifier use, support groups), mothers experiencing none were approximately eight times more likely to stop breastfeeding early. "]
["The baby friendly breast-feeding management course","British Journal of Midwifery","Dinwoodie, K., R. Bramwell, F. Dykes, S. Lang, and A. Runcieman. “The Baby Friendly Breast-Feeding Management Course.” British Journal of Midwifery 8, no. 6 (2000): 362–66.",1993,"UK","Hospital & Community","BHFI overall/all steps ","Health workers","To evaluate the impact on practitioners 6 months following completion of a BFI course in breastfeeding management. ","The findings showed that course members reported a sustained increase in knowledge, skills and positive attitudes concerning breast-feeding and that the course had increased confidence to activelysupport breast-feeding mothers and their infants\n\nOf the skills taught on the course, correct attachment to the mother's breast and hand expression were recorded as the most valuable. These two skills are fundamental to the achievement of breast-feeding. The fact that course participants rated these skills highly suggests that previous teaching on breastfeeding has not adequately covered these basic skills. The ability to use theseskills led practitioners to feel increasingly confident in being able to help women with breastfeeding difficulties"]
["Adherence to the Ten Steps of the Baby-FriendlyHospital Initiative in Minnesota Hospitals","Birth","Dodgson, J. E., C. J. Allard-Hale, A. Bramscher, F. Brown, and L. Duckett. “Adherence to the Ten Steps of the Baby-Friendly Hospital Initiative in Minnesota Hospitals.” Birth 26, no. 4 (1999): 239–47. https://doi.org/10.1046/j.1523-536x.1999.00239.x.",1993,"United States","Hospital","BHFI overall/all steps ","Postpartum women","1. To determine the in-hospital breastfeeding rate for Minnesota hospitals\n2. To analyze the relationship between the in-hospital breastfeeding rates and selected hospital  demographic  characteristics\n3. To  determine  the  rate  of  adherence  to  each  of  theBaby-Friendly Hospital Initiative (BFHI) Ten Steps, \n4. to analyse the relationship between the adherence rates for each of the Ten  Steps and selected demographic characteristics","The average breastfeeding initiation rate was 59%.\n\n- Step 1: 62% of hospitals had written policies. Only 3 hospitals had no policies.  \nStep 2: Basic BF education was offered to most nursing staff at all levels (88%)\nStep 3: not assessed \nStep 4: 88% of hospitals reported that vaginally delivered newborns breastfed within 1 hr of birth.\nStep 5: All 12 topics were taught in 61% or more of hospitals. 94% of hospitals instruction was done individually with postpartum women. \nStep 6: give newborn infants no food other than breastmilk.42%. only 7.7% of hospitals purchsed their human milk substitutes.56% of hospitals provdied commercially donated formula discharge packs to all new mothers. \nStep 7: Rooming in occured in 42% of hospitals.  \nStep 8: encourage breastfeeding on demand. 71%\nStep 9: no artificial teats, pacifiers etc. 2.6%\nStep 10: foster BF support groups: 8%.\n"]
["Exposure to Baby-Friendly Hospital Practices and Breastfeeding Outcomes of WIC Participants in Maryland","Journal of Human Lactation","Ducharme-Smith, K., S. M. Gross, A. Resnik, N. Rosenblum, C. Dillaway, D. Orta Aleman, M. Augustyn, J. Silbert-Flagg, and L. E. Caulfield. “Exposure to Baby-Friendly Hospital Practices and Breastfeeding Outcomes of WIC Participants in Maryland.” J Hum Lact 38, no. 1 (2022): 78–88. https://doi.org/10.1177/0890334421993771.",2022,"United States","Hospital","BHFI overall/all steps ","Postpartum women","(1) To compare maternal perceptions about maternity practices in Baby-Friendly Hospitals and non-Baby-Friendly Hospitals; (2) to evaluate the associations between degree of exposure to the Baby-Friendly 10 Steps and breast-feeding practices through the first 6 months; and (3) to evaluate whether the receipt of specific Steps was associated with breastfeeding practices through 6 months.","Reported adherence to 10-Steps policies ranged from 10%  (lowest for Step 9, highest for Step 10) and only Step 9 (give no pacifiers or artificial nipples to breastfeeding infants) differed according to Baby-Friendly Hospital status. Greater exposure to the 10 Steps was positively associated with exclusive breastfeeding during hospitalization. The lack of perceived adherence to Step 6 (no food or drink other than human milk), Step 9, and the International Code of Marketing of Breast-milk Substitutes (no formula, bottles, or artificial nipples) significantly decreased the likelihood of exclusive breast-feeding through 6 months."]
["Evaluation of a training program for healthcare professionals about breast-feeding","European Journal of Obstetrics & Gynecology","Durand, M., J. Labarère, E. Brunet, and J. C. Pons. “Evaluation of a Training Program for Healthcare Professionals about Breast-Feeding.” Eur J Obstet Gynecol Reprod Biol 106, no. 2 (2003): 134–38. https://doi.org/10.1016/s0301-2115(02)00225-7.",2003,"France ","Hospital","Step 2","Health workers and postpartum women","To assess the impact of a training program on maternity ward practices and on the duration of breastfeeding","76% of mothers initiated breast-feeding in the two samples. \n\nThe median duration of breast-feeding was 12 weeks and did not differ between the before and after groups.\n\nThe percentage of newborns separated from their mother more than 4 h a night decreased substantially after the intervention (13% versus 52%before the intervention,P<0:01). \n\nIn-hospital formula provision also decreased after the intervention."]
["Impact of a Baby-Friendlyâˆ’Aligned Pacifier Policyon Pacifier Use at 1 Month of Age","Academic Pediatrics","Ekambaram, M., M. M. Irigoyen, A. Paoletti, and I. Siddiqui. “Impact of a Baby-Friendly-Aligned Pacifier Policy on Pacifier Use at 1 Month of Age.” Acad Pediatr 19, no. 7 (2019): 808–14. https://doi.org/10.1016/j.acap.2019.02.002.",2019,"United States","Hospital","Step 9","Newborns and postpartum women","We evaluated the impact of a pacifier policy aligned with the World Health Organization and United Nations Children's Fund Baby-Friendly Hospital Initiative on subsequent pacifier use and breastfeeding at 1 month of age. ","Pacifier adoption was delayed in the post-implementation group, but pacifier use by 1 month of age was comparable (78.9% pre-implementation vs77.6% post-implementation;P= .793). \n- In the pre-implementation group, female and male infants used pacifiers at comparable rates; however, in the post-implementation group, females were significantly less likely to use a pacifier compared tomales after controlling for insurance, race, parity, and delivery mode.  \n- In the post-implementation group, exclusive breastfeeding rates at discharge increased significantly(from 40% to 51.3%;P= .04), but rates were not different at 1 month (23.7% pre-implementation vs 24.3% post-implemen-tation;P=.89)"]
["Evaluation of Breastfeeding in a Baby-friendly city, Corum, Turkey ","Cent Eur J Public Health ","Erkul, P. E., S. S. Yalçin, and S. Kiliç. “Evaluation of Breastfeeding in a Baby-Friendly City, Corum, Turkey.” Cent Eur J Public Health 18, no. 1 (2010): 31–37.",2010,"Turkey","Hospital","BHFI overall/all steps ","Postpartum women","The aim of this study was to evaluate the breast feeding status and the effect of lactation counseling support (LCS) on breastfeeding and social support in a Baby-Friendly City","Mothers who gave colostrum as the first food had more frequently taken lactation counselling support (LCS) than mothers who gave prelacteal foods.\n\nThe percentage of LCS in mothers who knew the expression of breast milk and didn't give bottle feeding was higher compared to others.\n\nLCS is very important for mothers to develop correct attitudes and behavior about breastfeeding and family collaboration.\n\nMothers supported by husbands, sisters and mothers-in-law participated more frequently in LCS than unsupported mothers. \n- Training of maternity ward staff and adoption of the Baby-Friendly Hospital Initiative are successful interventions to encour-age breastfeeding. \n- The Breastfeeding Center at Maternity ward and Children Hospital has employed peer counselors since September 2007 to provide services to breastfeeding women instudy location. Peer counseling programmes trained and employed women from the local commu-nity, who share the mother's social and cultural heritage"]
["The uptake and implementation of the Baby Friendly Health Initiative in Australia","Women and Birth","Esbati, A., A. Henderson, J. Taylor, and M. Barnes. “The Uptake and Implementation of the Baby Friendly Health Initiative in Australia.” Women Birth 32, no. 3 (2019): e323–33. https://doi.org/10.1016/j.wombi.2018.07.023.",2019,"Australia","Hospital & Community","BHFI overall/all steps ","Health workers","To explore health practitioners' perspectives about the uptake and implementation of the Initiative in Australia","Participants suggested that complexities of accreditation and reaccreditation processes impacted the uptake and implementation of the BFHI. These complexities included organisational size and their geographic allocation, prolonged processes of BFHI accreditation and reaccreditation, and maintaining standards required for BFHI reaccreditation.\n\nParticipants identified the need for improved policies and guidelines to support the uptake and implementation of the BFHI.\n                                                                                                                                                                                                                                                                This included support for implementing both the International Code of Marketing of Breastmilk Substitutes and the BFHI within maternity settings.\n-  Supportive leadership at national and local levels to ensure adequate resources for organisations, staff, and mothers was recommended by participants.\n- Providing sufficient information for mothers and public about the BFHI, the benefits of breastfeeding, disadvantages of not breastfeeding, and benefits of going to accredited facilities were identified by Participants as beneficial.\n- Participants recommended that improved communication at national, local and individual levels in relation to the uptake and implementation of the BFHI was needed. This included communication among healthcare staff ,between staff and mothers and between lead organisations and hospitals."]
["Perspectives about the baby friendly hospital/health initiative in Australia: an online survey","International Breastfeeding Journal","Esbati, A., J. Taylor, A. Henderson, M. Barnes, and L. Kearney. “Perspectives about the Baby Friendly Hospital/Health Initiative in Australia: An Online Survey.” Int Breastfeed J 15, no. 1 (2020): 23. https://doi.org/10.1186/s13006-020-00266-z.",2020,"Australia","Hospital","BHFI overall/all steps ","Health workers","To explore health professionals and other stakeholders' perspectives on the uptake and implementation of the BFHI in Australia from an organisational change perspective.","The majority of Participants supported legislating the who Code, closely monitoring BFHI compliance,ensuring sufficient knowledge about breastfeeding and the BFHI among staff, improving care within maternity facilities, continuous support of mothers' post-discharge, and improving social media support of breastfeeding.\n\nIt was also perceived that an interdisciplinary team approach and multidisciplinary involvement were important requirements for successfully implementing the BFHI. There was no consensus among Participants that Australian Health policies support breastfeeding and the implementation of the BFHI."]
["The impact of Baby Friendly Initiative accreditation: An overview of systematic reviews","Maternal & Child Nutrition","Fair, F. J., A. Morrison, and H. Soltani. “The Impact of Baby Friendly Initiative Accreditation: An Overview of Systematic Reviews.” Matern Child Nutr 17, no. 4 (2021): e13216. https://doi.org/10.1111/mcn.13216.",2021,"Overview of reviews- global literature","Hospital","BHFI overall/all steps ","Academic review","To examine the state of literature on the effects of BFI accreditation.","Most evidence suggests some increase in breastfeeding initiation, exclusivity and dura-tion of breastfeeding, and one main trial suggests decreased gastrointestinal infection and allergic dermatitis in infants. However, overall certainty in the evidence was rated as very low across all outcomes due to concerns over risk of bias within and heterogeneity between the original studies.\n\nThe results of this overview suggest that BFI accreditation may improve breastfeeding initiation and duration of exclusive and any breastfeeding, although no differences were seen within one review investigating longer term breastfeeding between 6 and 23 months.There is limited current evidence around the impact of BFI on mater-nal and infant health outcomes. Confidence in this evidence was how-ever judged to be very low for all outcomes."]
["The Baby Friendly Hospital Initiative and Breastfeeding Duration: Relating the Evidence to the Australian Context ","Birth Issues ","Fallon, A., M. Crepinsek, D. Hegney, and M. O’Brien. “The Baby-Friendly Hospital Initiative and Breastfeeding Duration: Relating the Evidence to the Australian Context.” Birth Issues 14, no. 3 (2005): 90–95.",2005,"Australia","Hospital & Community","BHFI overall/all steps ","Newborns and postpartum women","The purpose of this review is to present evidence related to the BFHI's impact upon breastfeeding duration, comment upon the relevance of this evidence to the Australian context, with a view to engendering discussion about the value of the BFHI in an environment where enhancement of breastfeeding duration appears to be the primary goal ","While the BFHI itself has been shown to increase the duration of exclusive breastfeeding, much of the evidence is derived from studies where exclusive breastfeeding initiation is low prior to implementation or There are major socioeconomic or cultural differences between Study contexts and the context observed in Australia.\n\nThere is little evidence to suggest that BFHI implementation has a positive impact upon breastfeeding duration in the Australian context."]
["The impact of the UK Baby Friendly Initiative on maternal andinfant health outcomes: A mixedâ€\u0090methods systematic review","Maternal and Child Nutrition","Fallon, V. M., J. A. Harrold, and A. Chisholm. “The Impact of the UK Baby Friendly Initiative on Maternal and Infant Health Outcomes: A Mixed-Methods Systematic Review.” Matern Child Nutr 15, no. 3 (2019): e12778. https://doi.org/10.1111/mcn.12778.",2018,"UK","Hospital & Community","BHFI overall/all steps ","Newborns and postpartum women"," To (a) examine the impact of BFI implementation (hospital and community) on maternal and infant health outcomes in the United Kingdom(UK) and (b) explore the experiences and views of women receiving BFIâ€\u0090compliant carein the UK. ","- There is insufficient evidence to draw firm conclusions about the impact of BFI implementation on maternal and infant health outcomes in the UK. \n- There is no data available relating to wider physical maternal or infant health outcomes.\n- 2 quantitative  studies indicate that BFHI implementation has a positive impact on breastfeeding to one week but this is not sustained. \n- No evaluation of the full BFCI programme is available.\n- support is highly influential to women's experiences of BFIâ€\u0090compliant care, but current provision may promote unrealistic expectations of breastfeeding, not meet women's individual needs, and foster  negative  emotional  experiences. "]
["Lessons Learned from Hospital Leaders Who Participatedin a National Effort to Improve Maternity Care Practices and Breastfeeding","Breastfeeding Medicine","Feldman-Winter, L., and J. Ustianov. “Lessons Learned from Hospital Leaders Who Participated in a National Effort to Improve Maternity Care Practices and Breastfeeding.” Breastfeed Med 11, no. 4 (2016): 166–72. https://doi.org/10.1089/bfm.2016.0003.",2016,"United States","Hospital","Becoming/pre BFHI","Key Informants Hospital: Senior Hospital Administrative Leaders ","Members of the Leadership Track were continually engaged and surveyed throughoutthe project period to provide feedback on the collaborative process and project as a whole","The leadership Track allowed hospital leaders to learn andsupport each other throughout the process of transformationalchange at their facilities. as a result, leaders played a key rolein  the  success  of  BFB,  and  an  unprecedented  number  ofnewly  designated  Baby-Friendly  hospitals  were  created  aspart of This one national collaborative.\n\nGovernment involvement in healthcare Plays a key Role in how leadership Leads\n\nLeaders for This kind of Initiative can be found in manydifferent roles and settings. some of the Participants in the leadership  Track  were  CEOs,  Directors  of  lactation  Ser-vices, or unit managers. However, the majority were serviceline managers, such as Directors of Maternal and Child Services. We observed that the key determinant of how muchimpact each leader had with respect to change initiatives wasnot  their 'level' of  leadership  but  rather  their  Role  in  theculture of their organization.\n\nLeaders need training in QI Methodology"]
["Best Fed Beginnings: A Nationwide Quality Improvement Initiative to Increase Breastfeeding ","Pediatrics","Feldman-Winter, L., J. Ustianov, J. Anastasio, S. Butts-Dion, P. Heinrich, A. Merewood, K. Bugg, S. Donohue-Rolfe, and C. J. Homer. “Best Fed Beginnings: A Nationwide Quality Improvement Initiative to Increase Breastfeeding.” Pediatrics 140, no. 1 (2017). https://doi.org/10.1542/peds.2016-3121.",2017,"United States","Hospital","Becoming/pre BFHI","Newborns and postpartum women","A national quality improvement initiative 'Best Fed Beginnings' , enrolling 90 hospitals in a nationwide initiative to increase breastfeeding and achieve baby friendly designation. Data were collected on procees indicators aliged with BFHI 10 Steps ","Results: 72/90 hospitals received the BF designation by April 2016, nearly doubling the number of designated hospitals in the US. \nParticipation in the Bed Fed Beginnings initiative had high correlation with designation compared with hospital applicants not in the programme. BF increased from 70% to 83% and exclusive BF from 39% to 61%. \n\nDespite the fact that project teams were recruited based on the strength of their past QI research, we found wide variability in their understanding of improvement science and in the execution of PDSA cycles. One common observation was that project teams became caught in the 'Do' phase, jumping from 1 task to the next, versus processing the changes with staff and learning from the test.â€\u008d Another observation was that project teams spearheading the local work had challenges carving out time to conduct tests of change due to staff turnover, leadership changes, and changing or competing priorities. It is expected that with more experience in applying QI methods, hospitals will be better positioned to engage in large-scale transformational changes.\n\nProgress towards BF designation continued well after the intervention period ended, reflecting the possibility that the learning collaborative efforts were accompanies by improvements to the hospital infrastructure to support BF.\n"]
["National survey on breastfeeding knowledge amongst residents in Pediatrics in Spain","Rev Esp Salud PÃºblica","Fernandez-Vegue, M. G., and M. Menendez Orenga. “National Survey on Breastfeeding Knowledge amongst Residents in Pediatrics in Spain.” Revista Espanola de Salud Publica 93 (2019). http://scielo.isciii.es/scielo.php?script=sci_abstract&pid=S1135-57272019000100053&lng=en&nrm=iso&tlng=en.",2019,"Spain","Hospital","BHFI overall/all steps ","Health workers","To document breastfeeding knowledge in Pediatric residents, and its relationship with the BFHI (Baby Friendly Hospital Initiative) status of their hospital","- Training at a BF designa-ted hospital and attending specific courses are the factors associated with better scores.\n-  51% of residents did not know of the International Code  \n50% did not know how to recognize ba-sic warning signs in the breastfed newborn in the first days of life. \n- Residents  from  BFHI  hospitals achieved better results than those from non-BFHI hospitals. \n- Variability at non-BFHI hospitals was considerable, where some hospitals showed unacceptable scores. \nPrevalence of courses was greater at BFHI hospitals. "]
["Baby-friendly Hospital Initiative â€“ a policy of promoting, protecting and supporting breastfeeding","Acta Paul Enferm","Figueredo, Sonia Fontes, Maria José Guardiã Mattar, and Ana Cristina Freitas de Vilhena Abrão. “Baby-Friendly Hospital Initiative: A Policy of Promoting, Protecting and Supporting Breastfeeding.” Acta Paulista de Enfermagem 25, no. 3 (2012): 459–63.",2012,"Global review","Hospital","BHFI overall/all steps ","Health workers and postpartum women and their babies and policy","To conduct a literature review about the ten steps of  the Baby Friendly Hospital Initiative","The analyzed studies showed that changes in hospital practices according to the Ten Steps of BFHI increased the prevalence of breastfeeding. It highlighted negative impact of the use of pacifiers on BF.\n\nParticipation in groups before and after the birth was not shown to be significant with regard to the duration of EBF in the first three month.\n\nExistance of a written policy is associated with the increase in BF rates. \n- Acquisition of knowledge and attitude by HPs had an influence on BF\n- Instructions given to pregnant women favoured the practice of BF.\n- Early contact positively influenced the mother as regards BF.\n- If the mother has good knowledge, this may have influence on BF. \n- Some studies showed that professional support was effective in increasing the duration of  breastfeeding and in reducing early weaning, and so was the contribution made by visits from trained and laypersons."]
["Breastfeeding Promotion Plan in Madrid, Spain","Journal of Human Lactation ","Flores-Anton, Beatriz, Ma Carmen Temboury-Molina, Susana Ares-Segura, Celina Arana-Canedo-Argueelles, Concepcion Nicolas-Bueno, Cristina Navarro-Royo, Alberto Pardo-Hernandez, and Carmen Rosa Pallas-Alonso. “Breastfeeding Promotion Plan in Madrid, Spain.” Journal of Human Lactation 28, no. 3 (2012): 363–69. https://doi.org/10.1177/0890334412449516.",2012,"Spain","Hospital","BHFI overall/all steps ","Hospitals - implementation plans ","To report the creation and implementation of a plan to promote and improve the quality of breastfeeding care in public hospitals in the region of Madrid, according to the Baby-Friendly Hospital Initiative (BFHI) standards","- 13 maternity units (68.4%) established a breastfeeding committee, and 32 months after implementation of the plan, the other 6 hospitals have created one. \n- 9 training courses have been carried out to train professional experts on breastfeeding as trainers.\n- The 271 trainers provided 18-hour breastfeeding courses for 1423 professionals.\n- In 2009, there was only 1 BFHI-accredited hospital. Currently, 52.6% of the other 19 hospitals have some level of accreditation, and 2 are fully accredited. "]
["The Effect of a 20-Hour Baby-Friendly Hospital Initiative Training Program on Nursesâ€™Breastfeeding Knowledge, Attitudes andConfidence, in a Tertiary Hospital in Singapore","Am J Perinatol","Fok, D., H. F. Chang, L. Y. Meng, and Y. P. M. Ng. “The Effect of a 20-Hour Baby-Friendly Hospital Initiative Training Program on Nurses’ Breastfeeding Knowledge, Attitudes and Confidence, in a Tertiary Hospital in Singapore.” Am J Perinatol, 2020. https://doi.org/10.1055/s-0040-1716489.",2020,"Singapore","Hospital","BHFI overall/all steps ","Health workers","This study evaluates the impact of the 20-hour BFHI training course on  nurses' breastfeeding knowledge, attitude, and confidence in breastfeeding practice in a tertiary hospital in Singapore.","After training, there were significant improvements for 5 of 8 items in infant feeding knowledge, including greater awareness of the International Code of Marketing of Breastmilk Substitutes and medical contra indication for breastfeeding. - Participants reported more confidence in assisting mothers on breastfeeding, 77.1 to 88.5%; advising hand expressing breast milk, 75.7 to 86.5%; and advising attachment to the breast, 75.7 to 89.2% in 2014, compared with 2009. \n\nHowever, despite having high levels of confidence, only about half the nurses reported being able to assist mothers in breastfeeding, mainly due to time constraints."]
["The Baby-Friendly Hospital Initiative in Switzerland: Trends over a 9-Year Period","Journal of Human Lactation","Forrester-Knauss, C., S. Merten, C. Weiss, U. Ackermann-Liebrich, and E. Z. Stutz. “The Baby-Friendly Hospital Initiative in Switzerland: Trends over a 9-Year Period.” Journal of Human Lactation 29, no. 4 (2013): 510–16. https://doi.org/10.1177/0890334413483923.",2013,"Switzerland ","Hospital","Steps 4, 6, 7, 9","Newborns and postpartum women","This article reports the trends over a 9-year period for 4 steps of the Baby-Friendly Hospital Initiative (BFHI) (exclusive breastfeeding, uninterrupted rooming-in, no use of pacifiers, and initiation of breastfeeding within the first 2 hours after birth) during hospital stays in Switzerland","- Significant improvements were found for 3 of the 4 steps of the BFHI between 2000 and 2008: rates of exclusive breastfeeding during postpartum stay (35.9%-57.6%, P < .001), uninterrupted rooming-in (48.2%-73.1%, P < .001), and no use of pacifiers (33.6%-48.1%, P < .001). \n- Initiation of breastfeeding within the first 2 hours after birth was always > 90% and did not change significantly over the 9 years. \n- Exclusive breastfeeding during hospital stay was significantly related to no use of pacifiers (P < .001) and to uninterrupted rooming-in (P < .001) in the years when exclusive breastfeeding particularly increased (2003, 2004, and 2008)"]
["Neonatal intensive care unit admissions beforeand after the adoption of the baby friendly hospital initiative","The Journal of Maternal-Fetal & Neonatal Medicine","Fradkin, E. C., M. A. Lafferty, J. S. Greenspan, and Z. H. Aghai. “Neonatal Intensive Care Unit Admissions before and after the Adoption of the Baby Friendly Hospital Initiative.” J Matern Fetal Neonatal Med 35, no. 4 (2022): 657–62. https://doi.org/10.1080/14767058.2020.1730796.",2022,"United States","Hospital","BHFI overall/all steps ","Newborns ","To determine if there was a change in admissions to the Neonatal Intensive CareUnit (NICU) from the newborn nursery after the adoption of BFHI in a large urban hospital.","There was no significant difference in the number of infants admitted from the newborn nursery either as a percentage of total deliveries (2.8 versus 2.9%, p=.6) or percentage of total NICU admissions (15.5 versus 15.5%,p=1.0) before and after the BFHI. Additionally, there was no difference in number of infantsadmitted with a diagnosis of possible sepsis, hypoglycemia, neonatal abstinence syndrome (NAS) and hyperbilirubinemia between the two groups. However, significantly more infantsadmitted with hypoglycemia required IV fluids for hypoglycemia after the initiation of BFHI (8 out of 27 versus 21 out of 28, p.001). The age of admission was higher and the duration of NICU stay was shorter in infants admitted after the initiation of the BFHI."]
["Neonatal intensive care unit admissions beforeand after the adoption of the baby friendlyhospital initiative","The Journal of Maternal-Fetal & Neonatal Medicine ","Fradkin, E. C., M. A. Lafferty, J. S. Greenspan, and Z. H. Aghai. “Neonatal Intensive Care Unit Admissions before and after the Adoption of the Baby Friendly Hospital Initiative.” J Matern Fetal Neonatal Med, 2020, 1–6. https://doi.org/10.1080/14767058.2020.1730796.",2020,"United States","Hospital","BHFI overall/all steps ","Newborns ","To determine if there was a change in number and type of admissions tothe Neonatal Intensive Care Unit (NICU) from the new-born nursery after the adoption of BFHI in a largeurban hospital in Philadelphia, PA, USA.","There was no significant difference in the number of infants admitted from the newborn nursery either as a percentage of total deliveries or percentage of total NICU admissions before and after the BFHI.\n- There was no difference in number of infants admitted with a diagnosis of possible sepsis, hypoglycemia, neonatal abstinence syndrome(NAS) and hyperbilirubinemia between the two groups. - However, significantly more infants admitted with hypoglycemia required IV fluids for hypoglycemia after the initiation of BFHI. - the age of admission was higher and the duration of NICU stay was shorter in infants admitted after the initiation of the BFHI"]
["Baby Friendly Hospital Initiative Breastfeeding Outcomes in Mothers with COVID-19 Infection During the First Weeks of the Pandemic in Spain","Journal of Human Lactation","Gabriel, M. A. M., L. D. Goneche, I. C. Perez, M. R. Vergeli, A. F. Buratti, A. R. Vicente, I. O. Arnal, et al. “Baby Friendly Hospital Initiative Breastfeeding Outcomes in Mothers with COVID-19 Infection During the First Weeks of the Pandemic in Spain.” Journal of Human Lactation 37, no. 4 (2021): 639–48. https://doi.org/10.1177/08903344211039182.",2021,"Spain","Hospital","BHFI overall/all steps ","Newborns ","Our study aims were: (1) to determine the breastfeeding rate during the first 6 months of life in children of mothers diagnosed with COVID-19 infection at the time of birth; and (2) to assess the possible influence of being born in a center with BFHI accreditation.","A total of 117 (47.3%) newborns were born in Baby-Friendly Hospital Initiative (BFHI) accredited centers. These centers applied skin-to-skin contact with greater probability (OR= 1.9; 95% CI [1.18, 3.29]) and separated the newborns from their mothers less frequently (OR= 0.46; 95% CI [0.26, 0.81]) than non-accredited centers. No differences were observed in relation to the presence of a companion at the time of birth. At discharge, 49.1% (n= 57) of newborns born in BFHI-accredited centers received exclusive breastfeeding versus 35.3% (n= 46) in non-accredited centers (p= .03). No differences were observed in breastfeeding rates throughout follow-up.\nThe exclusive breastfeeding rate at discharge in children of mothers with COVID-19 infection at birth was higher in Baby-Friendly Hospital Initiative accredited centers, which most frequently applied skin-to-skin contact at birth as well as rooming-in.\n\nThe number of newborns who required admission to the Neonatal Intensive Care Unit for reasons other than maternal COVID-19 infection was higher in BFHI-accredited centers, which may have resulted in the underestimation of the breastfeeding rate in different periods of the study (at discharge, and at 1, 3, and 6 months of age) in these hospitals. "]
["Becoming baby-friendly in Spain: a quality-improvement process","Acta Paediatrica","Garcia-de-Leon-Gonzalez, Ricardo, Antoni Oliver-Roig, Monica Hernandez-Martinez, Beatriz Mercader-Rodriguez, Veronica Munoz-Soler, Maria Isabel Maestre-Martinez, and Ana Belen Monreal-Tomas. “Becoming Baby-Friendly in Spain: A Quality-Improvement Process.” Acta Paediatrica 100, no. 3 (2011): 445–50. https://doi.org/10.1111/j.1651-2227.2010.02061.x.",2011,"Spain","Hospital","Becoming/pre BFHI","Newborns and postpartum women","To describe the effect of the quality-improvement intervention on compliance with the '10 steps' of the BFHI and onbreastfeeding rates during the process and following BFHI accreditation","- Compliance with the Global Criteria increased progressively, and in 2004all criteria were met. \n- The median duration of breastfeeding went up gradually from the startof the intervention. \n-The likelihood of being breastfed at different ages among infants bornin 2005 was between 45% and 86% higher than among infants born in 1997."]
["Evaluation of a lactation intervention program to encouragebreastfeeding: a longitudinal study","International Journal of Nursing Studies ","Gau, M. L. “Evaluation of a Lactation Intervention Program to Encourage Breastfeeding: A Longitudinal Study.” Int J Nurs Stud 41, no. 4 (2004): 425–35. https://doi.org/10.1016/j.ijnurstu.2003.11.002.",2004,"Taiwan","Hospital","BHFI overall/all steps ","Postpartum women","1. Compare the cases (with and without the lactation intervention programme) in regard to BF attitudes, BF knowledge, BF initiation, and BF rate. \n2. Analyse the yearly effects of the lactation intervention programme on BF initiation rate adn BF duration. \n3. Analyse the correlations between BF atitudes, BF knowledge, BF initiatin and BF rate. ","- The exclusive and overall breastfeeding rates of the experimental group were higher than those of the control group (po0:001); moreover, the breastfeeding rates generally exhibited an increasing trend year by year. \n- The experimental group scored higher in breastfeeding knowledge than the control group as did positive attitudes toward breastfeeding with scores increasing year by year. \n- Higher scores reflected better knowledge inbreastfeeding, and, in turn, a longer duration of breastfeeding"]
["Education and training of healthcare staff in the knowledge, attitudes and skillsneeded to work effectively withbreastfeeding women: a systematic review","International Breastfeeding Journal","Gavine, A., S. MacGillivray, M. J. Renfrew, L. Siebelt, H. Haggi, and A. McFadden. “Education and Training of Healthcare Staff in the Knowledge, Attitudes and Skills Needed to Work Effectively with Breastfeeding Women: A Systematic Review.” Int Breastfeed J 12 (2016): 6. https://doi.org/10.1186/s13006-016-0097-2.",2016,"Global review ","Hospital","Steps 3-9","Health workers","- The primary aim of this review of randomised con-trolled trials is to determine whether education andtraining programs for healthcare staff has an effect ontheir  knowledge  and  attitudes  about  supportingbreastfeeding women compared to no or usual train-ing (comparator). \n- The secondary aim of this reviewwas to identify if there were differences in terms of the type of training and the discipline of the health-care staff","- Knowledge was included as an outcome in two studies and demonstrated small but significant positive effects.\n- Attitudes towards breastfeeding was included as an outcome in two studies, however, results were inconsistentboth in terms of how they were measured and the intervention effects. - One study reported a small but significantpositive effect on BFHI compliance. - Study quality was generally deemed low with the majority of domains beingjudged as high or unclear risk of bias\n- A lack of studies exam-ining the impact of training and education on breast-feeding and supporting feeding practices for healthcarestaff. This is in stark contrast to a large number of RCTswhich have examined the impact of interventions tar-geted at mothers that aim to promote initiation (n=23included trials) and provide support for breastfeeding (n= 73 included trials"]
["Prevalence of breastfeeding and birth practices during the first wave of the COVID-19 pandemic within the Italian Baby-Friendly Hospital network. What have we learned?","Ann Ist Super SanitÃ ","Giusti, A., E. M. Chapin, S. Spila Alegiani, F. Marchetti, S. Sani, J. Preziosi, S. Colaceci, and F. Zambri. “Prevalence of Breastfeeding and Birth Practices during the First Wave of the COVID-19 Pandemic within the Italian Baby-Friendly Hospital Network. What Have We Learned?” Ann Ist Super Sanita 58, no. 2 (2022): 100–108. https://doi.org/10.4415/ann_22_02_05.",2022,"Italy","Hospital","BHFI overall/all steps ","Hospitals","To describe, in a number of facilities that are part of a national Baby-Friendly net-work, the adherence to some steps of BFHI standards during the COVID-19 emergency","Out of the 68 participating hospitals, 30.9% were hubs and 69.1% spokes. Dur-ing May 2020, 61.8% of hospitals had COVID-19 and non-COVID-19 clinical pathways, while 38.8% were only non-COVID-19. None was dedicated exclusively to COVID-19 pathways. The BFHI was effective in guaranteeing exclusive breastfeeding, the presence of companion of mother's choice, skin-to-skin and rooming-in. The type of accreditation was associated with the presence of a companion of the mother's choice during labour (p=0.022) and with skin-to-skin (p<0.001). A"]
["Evaluation of the Baby Friendly Hospital Initiative Programme in Two Hospitals Designated â€œBaby-Friendlyâ€\u009d in Kirkuk City, Iraq","Indian Journal of Public Health Research & Development ","Gli, F. A. A., D. Spence, L. Johnston, F. Lynn, R. Tubman, and Z. M. Sadiq. “Evaluation of the Baby Friendly Hospital Initiative Programme in Two Hospitals Designated ‘Baby-Friendly’ in Kirkuk City, Iraq.” Indian Journal of Public Health Research and Development 10, no. 9 (2019): 557–63. https://doi.org/10.5958/0976-5506.2019.02489.6.",2019,"Iraq ","Hospital","BHFI overall/all steps ","Health workers","1. to determine if the 2 BFHI designated hospitals in Kirkuk have sustained adherence to the 10 steps\n2. To assess the levels of support reported by clinical and non-clinical staff to successfully deliver the BFHI programme. ","- Compliance in both hospitals with step 1,7, and 10 of the Ten Steps and the Code. \n- Non compliance with Steps 3, 4,5,6,8,9\n-62% of participants reported that healthy full-term newborns within their care had started to BF within 60 minutes after birth. \n- Respondents agreed on the need for guidance and training (78%)\n"]
["Ten steps for successful breastfeeding: assessment of hospital performance, its determinants and planning for improvement","Child Care Health and Development","Gokcay, G. “Ten Steps for Successful Breast Feeding: Assessment of Hospital Performance, Its Determinants and Planning for Improvement.” Child Care Health and Development 23, no. 2 (1997): 187–200. https://doi.org/10.1111/j.1365-2214.1997.tb00892.x.",1993,"Turkey","Hospital","BHFI overall/all steps ","Health workers and postpartum women","To document the existing maternity hospital practices in Istanbul, to identify the determinants that affect the implementation of the Ten Steps in these  hospitals and  to make recommendations and plans for improvements","- Step 1: No hospital in our project had a written or unwritten breast-feeding policy that was routinely communicated  to all health care staff\n- Step 2: there had been no efforts to train personnel in the skills necessary to implement this policy. the majority of the health staff did not have adequate knowledge nor skill to implement a BF policy. \n- Step 3: None of the hospitals inform pregnant women about the benefits and manage- ment of BF. \n- Step 4: Helping mothers initiate breast-feeding within a half hour of birth was found to be too pushy by most of the physicians.\n- Step 5: Nurses in four hospitals were showing mothers how to breast-feed but they did not point out how to maintain lactation even if separated from their babies. Most of the staff were heavily dependent on pumps to assist mothers who had trouble breast-feeding. Staff  were hampered by lack of time for  two  reasons: the motherâ€™s very short stay and the low number of nurses. Also, nurses did not have enough information and counselling skills for BF and were not aware of the importance of this approach to successful BF.\n- Step 6: Only hospital B was making efforts to give newborns no food or drink other than breast-milk, unless medically indicated, but family members were creating prob- lems by offering water with added sugar to the newborn without asking the hospital staff. Also, physicians wanted the babies to have oral glucose  water if blood glucose was low. In addition, nurses and some physicians feared the baby would be dehydrated\n- Step 7: rooming-in was initiated in the two state hospitals, but the administrators and head physicians expressed some concerns. \n- Step 8: All hospitals except one private hospital which was strictly against the practice of rooming-in were trying to encourage BF on demand, but not successfully since the implementation of this step is dependent upon step 7\n- Step 9: No amficial  teats or pacifiers  were  given to the newborns in the two state hospitals. The staff of private  hospitals  said that it was  very  difficult to put limitations on the clients. Therefore if a mother wanted to give a pacifier to the baby the staff did not oppose this practice. On the  other hand, many of the nursing staff and/or mothers did not believe pacifiers were problematic.\n- Step 10: None of the hospitals in our project had med to establish BF support groups and refer mothers to them."]
["Hospital Care and Early Breastfeeding Outcomes Among Late Preterm, Early-Term,and Term Infants","BIRTH","Goyal, N. K., L. B. Attanasio, and K. B. Kozhimannil. “Hospital Care and Early Breastfeeding Outcomes among Late Preterm, Early-Term, and Term Infants.” Birth 41, no. 4 (2014): 330–38. https://doi.org/10.1111/birt.12135.",2014,"United States","Hospital","BHFI overall/all steps ","Postpartum women","The purpose of the current study is to determinewhether supportive hospital practices mediate the rela-tionship between gestational age at birth and breast-feeding outcomes at 1 week postpartum among latepreterm, early-term, and term newborns, adjusting for demographic and clinical factors. \n\nWe also  examined  women's  experiences  of  hospitalpractices consistent with the Baby-Friendly Hospital Initiative's  Ten  Steps  for  United  States  Hospitals","- High hospital support was associated with increased exclusive breastfeeding.\n- Just 16.4 percent of late preterm infants experienced such support, compared with  early-term  (37.9%)  and  term  (30.7%)  infants.\n-  Although overall breastfeeding rates among late preterm, early-term, and term infants were 87, 88, and 92% respectively, late preterm versus term infants were less likely to exclusively  breastfeed  (39.8  vs.  62.3%).  "]
["A multifaceted approach to revitalising the baby-friendly hospital initiave in Croatia","Journal of Human Lactation","Grguric, J., I. Zakarija-Grkovic, A. P. Bosnjak, and M. Stanojevic. “A Multifaceted Approach to Revitalizing the Baby-Friendly Hospital Initiative in Croatia.” Journal of Human Lactation 32, no. 3 (2016): 568–73. https://doi.org/10.1177/0890334415625872.",2016,"Croatia","Hospital","BHFI overall/all steps ","Academic - status of the BFHI ","- To describe the successful reintro-duction of the BFHI in Croatia between 2007 and 2015, including challenges encountered along the way, so that other countries may benefit from the shared experience","By June 2015, 30 of 32 (94%) maternity facilities, providing care to 89% of newborns, were Baby-Friendly. \n\nNine maternity hospitals have been renovated and 2 new hospitals have been built. \n\nExclusive breastfeeding rates have risen 16% at 0 to 2 months (from 51% in 2007 to 67% in 2014) and 14% at 3 to 5 months (from 32% in 2007 to 46% in 2014). \n\nFourteen 'Breastfeeding-Friendly' primary care practices have been designated, 166 breastfeeding support groups are in operation, criteria for Mother-Friendly care are being piloted in 2 maternity facilities, and 'Ten Steps in the Neonatal Intensive Care Unit' are being introduced.\n \nWhile almost all maternity facilities in Croatia are 'Baby-Friendly'\u009d there are problems related to obstetric care, mainly due to violations of women's reproductive health and human rights. This led to the inclusion of the Mother-Friendly Hospital Initiative (MFHI)11 in the National Breastfeeding Program for the period 2014 to 2016, since it was felt that true 'Baby-Friendly' care must include the well-being of mothers. Unlike the BHFI, the MFHI does not have universally accepted criteria for implementation, self-evaluation, and assessment."]
["Policies and Practices Related to Breastfeeding inMassachusetts: Hospital Implementation of theTen Steps to Successful Breastfeeding","Maternal and Child Health Journal ","Grizzard, T. A., M. Bartick, M. Nikolov, B. A. Griffin, and K. G. Lee. “Policies and Practices Related to Breastfeeding in Massachusetts: Hospital Implementation of the Ten Steps to Successful Breastfeeding.” Matern Child Health J 10, no. 3 (2006): 247–63. https://doi.org/10.1007/s10995-005-0065-8.",2006,"United States","Hospital","BHFI overall/all steps ","Newborns and postpartum women","1) Design and utilize aninstrument  to  measure  hospital  implementation  ofthe Ten Steps to Successful Breastfeeding;\n2) Assessthe  current  status  of  overall  Ten  Steps  implemen-tation as well as individual implementation of eachStep in Massachusetts hospitals; and \n3) To compare characteristics of hospitals with high versus low lev-els of implementation to identify areas for possible intervention","- Levels of implementation of the Ten Steps ranged from high to partial. \n-  2% of hospitals classified implementation as high, 58% moderately high, 40% partial, and 0% as low.\n- Hospitals with high/moderately high levels of implementation significantly differed from hospitals with partial implementation with respect to pacifier usage and postpartum breastfeeding instruction.\n- Requirement of a physician order for formula was a statistically significant predictor of Step 1 implementation but did not reach signif-icance overall. \n- Acceptance of free formula was significantly associated with overall Ten Steps implementation. "]
["Empowering women to breastfeed: Does the Baby Friendly Initiative make a difference?","Maternal and Child Nutrition","Groleau, D., K. W. Pizarro, L. Molino, K. Gray-Donald, and S. Semenic. “Empowering Women to Breastfeed: Does the Baby Friendly Initiative Make a Difference?” Matern Child Nutr 13, no. 4 (2017). https://doi.org/10.1111/mcn.12370.",2017,"Canada","Hospital & Community","BHFI overall/all steps ","Postpartum women","a)What are the subjective experiences of Qubec mothers regarding breastfeeding promotion and support services?\n(b)How do these serviceâ€\u0090related experiencesrelate to their social and embodied experience of breastfeeding?\n(c)How do these experiences vary according to the implementation level of BFI?","We found the flexible approach to breastfeeding duration, characteristic of BFI services in our Study, helped to avoid Maternal guilt and shame\n\nThe shift to focusing on potential barriers and strategies for overcoming them empowered women to negotiate changes in infant feeding with others and self by addressing the embodied experience of a practice that may not feel natural at the beginning."]
["Baby Friendly Hospital Designation and Breastfeeding Outcomes Among Maryland WIC Participants","Maternal and Child Health Journal ","Gross, S. M., D. Orta-Aleman, A. K. Resnik, K. Ducharme-Smith, M. Augustyn, J. Silbert-Flagg, N. Rosenblum, and L. E. Caulfield. “Baby Friendly Hospital Designation and Breastfeeding Outcomes Among Maryland WIC Participants.” Matern Child Health J 26, no. 5 (2022): 1153–59. https://doi.org/10.1007/s10995-022-03410-9.",2022,"United States","Hospital","BHFI overall/all steps ","Newborns and postpartum women","to evaluate whether Baby Friendly Hospital (BFH) designation in Maryland improved breastfeeding practices among Special Supplemental Nutrition Program for Women, Infants and Children (WIC) participants","From pre to post intervention no differences in breastfeeding initiation or any breastfeeding at 6 months were attribut-able to BFH status. There was some evidence that BFH designation in 2016 was associated with an absolute percent change of 2.4% (P = 0.09) for any breastfeeding at 3 months."]
["Cyprus mothers' breast feeding self-efficacy and their perceptions about the implementation of theâ€˜10 stepsâ€™ in the first 48 hours after birth","Midwifery","Hadjiona, V., N. Middleton, C. Kouta, E. Hadjigeorgiou, E. Lambrinou, and O. Kolokotroni. “Cyprus Mothers׳ Breast Feeding Self-Efficacy and Their Perceptions about the Implementation of the ‘10 Steps’ in the First 48hours after Birth.” Midwifery 36 (2016): 43–52. https://doi.org/10.1016/j.midw.2016.02.021.",2016,"Cyprus","Hospital","BHFI overall/all steps ","Postpartum women","This study assessed breast feeding self-efficacy among mothers during thefirst 48 hours after birthand explored their views with regards to the implementation of the '10 steps' across public and privatematernity units in Nicosia, Cyprus","- Midwifery assistance for breast feeding skills development along with encouragement of breastfeeding on demand (steps 5 and 8) were identified by mothers as the steps they were more likely to have experienced. \n- There appeared to be relatively good adherence to the International Code of Marketing of Breastmilk Substitutes. \nIn contrast, it seems that step 7(rooming-in), step 9 (no pacifiers)and step 10 (breast feeding support after discharge) were not systematically practiced. \n- While a higher percentage of mothers in public maternity units reported being informed about the importance of skin-to-skin contact compared to the private sector (51.5% versus 25.7%), there does not appear to be much difference in terms of its actual practice which is generally low (29.0% versus 25.4%). \n- Exclusive breastfeeding (step 6) was low (21.7%) while the mean score of breast feeding self-efficacy at 48 hours was 3.33(0.87SD) on a 5-point Likert scale"]
["Compliance with Baby-Friendly  Policies and Practices in Hospitals and Community Health Centers in Quebec","Journal of Human Lactation","Haiek, L. N. “Compliance with Baby-Friendly Policies and Practices in Hospitals and Community Health Centers in Quebec.” J Hum Lact 28, no. 3 (2012): 343–58. https://doi.org/10.1177/0890334412448477.",2012,"Canada","Hospital & Community","BHFI overall/all steps ","Health workers, postpartum women and staff/managers ","(1) to assess the level of implementation of the BFI in response to the breastfeeding guidelines published in 2018 as well as a midway evaluation of the provincial public health program \n(2) to provide birthing facilities and CHCs with pertinent information to help them implement the latest international recommendations.","- Mean compliance scores in Quebec were 3.13 for 140 CHCs and 4.54 for 60 hospitals/birthing centers. \n- The evaluation documented marked variations in implementation level for each of the steps/points and the Code.\n- Managers/staff, mothers, and observers differed in their report of BFI compliance for most steps/points and the Code. \n- Facilities that had applied for or obtained BFI designation demonstrated higher compliance with the BFI than those that had not. \n- we found a disconnect in breastfeeding-related counseling in both CHCs and hospitals, with wide differences between what staff reported teaching to mothers and what mothers reported having been taught on a given topic,"]
["Measuring compliance with the Baby-Friendly Hospital Initiative","Public Health Nutrition","Haiek, L. N. “Measuring Compliance with the Baby-Friendly Hospital Initiative.” Public Health Nutr 15, no. 5 (2012): 894–905. https://doi.org/10.1017/s1368980011002394.",2011,"Canada","Hospital","BHFI overall/all steps ","Health workers, postpartum women and staff/managers ","This paper describes the development of a computer-@based instrument that measures policies and practices outlined in the BFHI","8 of 9 hospitals increased both the Ten Steps and Code  Global  Compliance  Scores  over  time,  frequently dramatically.\n\nExamples of actions undertaken at the regional level to address gaps in  compliance  with  Step  4  and  other  BFHI  practices include: adapting training materials, using a regional col-=laborative approach to discuss challenges identified in the assessments, share strategies and invite champions to pre-sent creative solutions. \n\nIn the case of Hospital F, concreteactions in regard to Step 4 were taken only in 2004 after managers and clinicians forming a breast-feeding commit-tee used monitoring results from the first two assessments to identify  areas  needing  improvement.  \n\nChanges were introduced gradually, involving all maternity unit staff andaimed  at  improving  nursing  competency.  These  efforts resulted  in  a  doubling  of  Step  4  Partial  Compliance Score between 2001-2004 and 2007."]
["Maternity ward staff perceptions of exclusive breastfeeding in Finnish maternity hospitals: A cross-sectional study","European Journal of Midwifery","Hakala, M., P. Kaakinen, M. Kääriäinen, R. Bloigu, L. Hannula, and S. Elo. “Maternity Ward Staff Perceptions of Exclusive Breastfeeding in Finnish Maternity Hospitals: A Cross-Sectional Study.” Eur J Midwifery 5 (2021): 16. https://doi.org/10.18332/ejm/134846.",2021,"Finland","Hospital","BHFI overall/all steps ","Health workers","To describe exclusive breastfeeding (EBF, Step 6 of the Baby-Friendly Hospital Initiative) in Finnish maternity hospitals and identify factors that promote or limit EBF","Maternity ward staff reported that 72% (n=1105) of the infants were exclusively breastfed during their work shift. The strongest promoting factors of exclusive breastfeeding were: maternity ward staffs' profession and education in breastfeeding counselling; multiparity; vaginal delivery; early skin-to-skin contact between mother and infant; initial breastfeeding after birth; rooming-in; and initial success of breastfeeding. The use of a nipple shield, the need for additional breastfeeding counselling, and infants' blood tests were limiting factors to exclusive breastfeeding. Open-ended answers revealed that exclusive breastfeeding was mainly delayed because of medical issues for the mother or infant"]
["An Exploratory Study of the Associations Between the Hospital Work Environment and Implementation of Baby-Friendly Hospital Policy","The Journal of Perinatal Education","Hallowell, Sunny G. “An Exploratory Study of the Associations Between the Hospital Work Environment and Implementation of Baby-Friendly Hospital Policy.” Journal of Perinatal Education 33, no. 3 (2022): 142–50. https://doi.org/10.1891/JPE-2021-0004.",2021,"United States","Hospital","BHFI overall/all steps ","Health workers","to explore the relationships between the hospital work environment and implementation of the Baby-Friendly USA Ten Steps Policy in an urban hospital.","Nurses reported the degree to which the Ten Steps policy was implemented, perceptions of the unit work environment using the Practice Environment Scale of the Nursing Work Index (PES-NWI), and self-efficacy related to the implementation of the policy. Results suggest that the work environment and the implementation of breastfeeding policy have separate and independent effects on nurse self-efficacy. Robust nursing leadership focused on education and skill development for clinicians, and focused on post-hospital care for patients and families are important contributory factors to successful breastfeeding policy implementation."]
["A systematic review of professional support interventions forbreastfeeding","Journal of Clinical Nursing","Hannula, Leena, Marja Kaunonen, and Marja-Terttu Tarkka. “A Systematic Review of Professional Support Interventions for Breastfeeding.” Journal of Clinical Nursing (Wiley-Blackwell) 17, no. 9 (2008): 1132–43. https://doi.org/10.1111/j.1365-2702.2007.02239.x.",2008,"Europe, North America, Australia or New Zealand","Hospital & Community","BHFI overall/all steps ","Health workers","1. How breastfeeding was professionally supported (a) during the pregnancy (b) at the maternity hospital and (c) during postnatal time?\n2. How effective are professional interventions in supporting breastfeeding?","Six of the studies evaluated the effect of the BFHI as anintervention. BFHI was very effective in increasing breast-feeding initiation and duration in Belarus (Krameret  al.2001).\n\nIn a Swiss study, children born in hospitals with high compliance of BFHI guidelines were more likely to bebreastfed for longer (Mertenet al.2005).\n\nA German study(Dulonet  al.2003) shared similar results. \n\nEven moderate levels of breastfeeding promotion in hospitals identified by BFHI criteria resulted in longer-term breastfeeding success.\n\nFull implementation of BFHI programme was an effective intervention to increase breastfeeding and exclusive breast-feeding in the USA (Philippet al.2001).\n\nA USA study examined the BFHI steps effect on breast-feeding continuation. The strongest risk factors for earlybreastfeeding termination were late initiation and formula supplementation. \n\nMothers experiencing no BFHI practicesare eight times more likely to stop breastfeeding than motherswho experienced five BFHI practices.\n\nEven gradual applica-tion of BFHI practices will have an effect on breastfeeding (DiGirolamoet  al.2001).\n\nA single Swiss RCT (Kindet  al.2000) had different results. The aim of the study was to evaluate whether restriction of supplementary fluids andavoidance of teats and pacifiers affect later breastfeeding success. There was very little difference between the inter-vention- and control group in the results, but the interventionwas not carried out as planned. In total, 85% of newborns inthe intervention group (no supplementation) received sup-plements compared with 97% of the control group. - The quality of the study was rated poor and the results are therefore unreliable or questionable"]
["Improving Hospital Breastfeeding Policies in New York State:Development of the Model Hospital Breastfeeding Policy","Breastfeeding Medicine ","Hawke, B. A., B. A. Dennison, and S. Hisgen. “Improving Hospital Breastfeeding Policies in New York State: Development of the Model Hospital Breastfeeding Policy.” Breastfeed Med 8, no. 1 (2013): 3–7. https://doi.org/10.1089/bfm.2012.0030.",2013,"United States","Hospital","BHFI overall/all steps ","Hospital policies ","This article de-scribes the assessment of these written hospital breastfeedingpolicies and the development of the NYS Model Hospital Breastfeeding Policy","- Approximately half (19/32) the components required under NYS hospital regulations were included. \n- Inclusion of each of theTen Steps varied from 14% to 98%. \n\n- Step 1: 14%\n- Step 2: 59%\n- Step 3: 19%\n- Step 4: 91%\n- Step 5: 74%\n- Step 6: 90%\n- Step 7: 79%\n- Step 8: 98%\n- Step 9: 60%\n- Step 10: 73%\n- An evidence-based Model Hospital Breastfeeding Policy was developed that included required components (based on NYS hospital regulations andlegislation) and recommendations from expert groups such as the Academy of Breastfeeding Medicine, BabyFriendly USA, Inc., and the United States Breastfeeding Committee. "]
["Compliance with the Baby-Friendly Hospital Initiative and impacton breastfeeding rates","Arch Dis Child Fetal Neonatal Ed","Hawkins, S. S., A. D. Stern, C. F. Baum, and M. W. Gillman. “Compliance with the Baby-Friendly Hospital Initiative and Impact on Breastfeeding Rates.” Arch Dis Child Fetal Neonatal Ed 99, no. 2 (2014): F138-43. https://doi.org/10.1136/archdischild-2013-304842.",2014,"United States","Hospital","BHFI overall/all steps ","Postpartum women","To examine compliance with the BFHI as well as evaluate the BFHI and its components on breastfeeding initiation and duration overall and according to Maternal education level.","- 34.6% of mothers from BFHI-accredited facilities reported experiencing all 7 BFHI breastfeeding practices compared to 27.1% of mothers from non-BFHI facilities \n-  For Steps 4 to 9, compliance fo rBFHI facilities postaccreditation ranged from 57% to 87%. The largest difference across facility type was seen for the non-BFHI practice on giving mothers gift packs with formula.\n- Mothers who gave birth in non-BFHI facilities were twice as likely to report they were givena gift pack with formula than mothers who gave birth in BFHI facilities preaccreditation or post accreditation (67% vs 35% vs 28%), respectively.\n- Among mothers with lower education, the BFHI increased breastfeeding initiation by 8.6% and, independently, each additional breastfeeding practice was associated with an average increase in breastfeeding initiation of 16.2%. \n- Among all mothers and mothers with higher education, there was no effect of the BFHI on breastfeeding rates. "]
["Evaluating the impact of the Baby-Friendly Hospital Initiative on breastfeeding rates: a multi-state analysis","Public Health Nutrition","Hawkins, S. S., A. D. Stern, C. F. Baum, and M. W. Gillman. “Evaluating the Impact of the Baby-Friendly Hospital Initiative on Breast-Feeding Rates: A Multi-State Analysis.” Public Health Nutr 18, no. 2 (2015): 189–97. https://doi.org/10.1017/s1368980014000238.",2015,"United States","Hospital","BHFI overall/all steps ","Postpartum women","To evaluate the impact of the Baby-Friendly Hospital Initiative (BFHI)on breast-feeding initiation and duration overall and according to maternal education","- The main finding of the present study is that althoughBFHI  accreditation  did  not  increase  breast-feedinginitiation or duration overall compared with non-Baby-Friendly  hospitals,  it  benefited  mothers  with  lower education\n- No overall differences in breastfeeding initiation between birth facilities that received BFHI accreditation compared with non-Baby-Friendly facilities  \n- Breastfeeding initiation increased by 3.8% among mothers with lower education who delivered in Baby-Friendly facilities , but not among mothers with higher education \n- BFHI accreditation also increased exclusive breast-feeding for greater or equal to 4 weeks by 4.5% among mothers with lower education who delivered in BFHI facilities\n- Breast-feeding initiation for Hispanic mothers was, on average,7?4 percentage points higher than for white mothers.\n- In analyses exploring the timing of BFHI accreditation,there was no effect of the policy either 6 months or24 months prior to the actual date of accreditation onbreast-feeding initiation. We observed increased breast-feeding initiation only among mothers who gave birth in  hospitals  post-accreditation. \n-  it is unlikely that hospitals had policies inplace supporting breast-feeding prior to their accreditation; rather the data provide evidence for a direct effectof  BFHI  accreditation on subsequent  breast-feeding initiation. "]
["Breastfeeding,baby friendliness and birth in transition in North Western Russia: a study of womenâ€™s perceptions of the care they receive when giving birth in six maternity homes in the cities of Archangelsk and Murmansk,1999","Acta Paediatrica","Helsing, E., B. E. Chalmers, T. J. Dinekina, and N. I. Kondakova. “Breastfeeding, Baby Friendliness and Birth in Transition in North Western Russia: A Study of Women’s Perceptions of the Care They Receive When Giving Birth in Six Maternity Homes in the Cities of Archangelsk and Murmansk, 1999.” Acta Paediatr 91, no. 5 (2002): 578–83. https://doi.org/10.1080/080352502753711722.",2002,"Russia ","Hospital","BHFI overall/all steps ","Postpartum women","1.To assess Russian women's perceptions of their breastfeeding and birthing experiences in settings that were assumed to differ significantly.\n2.To determine whether there had been a carryover effect in to obstetric practices of the attitudes to care that are implicit in the BFHI","Staff at the BFH practised routines and procedures that are known to support BF more frequently than staff at the NBFH. \n\nBFH mothers described several of the classical problems usually related to poor breastfeeding management, such as engorgement, cracked nipples and severe pain, slightly more often than mothers in the NBFH. \n\nInverted nipples and illness in the mother tended to be reported more often in the NBFH than in the BFH.\n\nMore women in the BFH than in the NBFH reported that they were being well prepared for labour (74.1%vs58.2%), and a shaving acquired information about infant feeding and family planning before the birth. \n\nThere was no difference in the reported incidence of various forms of induction between the two groups.\n\nMothers in the BFH reported a slightly more frequent use of Electronic Foetal Heart Monitoring ,pain medication, pubic and perineal shaving and intravenous drip\n\nThere was also payment for services:14.6%of BFH and 7.7% of NBFH mothers told of having paid to get a single room, while 12.3% of the BFH and 3.3% of the NBFH mothers reported that they had paid for their husbands to be with them for delivery."]
["Racial Disparities in Sustaining Breastfeeding in a Baby-Friendly Designated Southeastern United States Hospital:An Opportunity to Investigate Systemic Racism","BREASTFEEDING MEDICINE","Hemingway, S., Z. Forson-Dare, M. Ebeling, and S. N. Taylor. “Racial Disparities in Sustaining Breastfeeding in a Baby-Friendly Designated Southeastern United States Hospital: An Opportunity to Investigate Systemic Racism.” Breastfeed Med 16, no. 2 (2021): 150–55. https://doi.org/10.1089/bfm.2020.0306.",2021,"United States","Hospital","BHFI overall/all steps ","Postpartum women","Through an institutional Perinatal Information Systems database, breastfeeding rates were compared before and after BFHI implementation. Breastfeeding initiation, sustained breastfeeding 24-hours before discharge, and patient demographics were assessed, to accertain if racial disparities in breastfeeding rates persist in the United States - with Black women historically having the lowest rates of BF initiation and continuation. ","After BFHI implementation, mothers were overall 1.17  times more likely to initiate breastfeeding. For Black mothers, breastfeeding initiation increased significantly from 52% to 66%, but they were significantly less likely to sustain in-hospital breastfeeding compared to non-Black  mothers.  Several  demographic  and  medical  comorbidities  were significantly  associated  with  failure  to  sustain  breastfeeding  to  hospital  discharge.  When  controlling  forthese factors, the racial disparity persisted.\n\nSince  BFHI  implementation,  the  racial  gap  in breastfeeding  initiation  decreased,  but  a  significant disparity remained for sustained in-hospital breastfeeding. This study highlights the success of the BFHI program. Nevertheless; there are a dearth of Black lactation consultants, and it is increasingly  recognized  that  they  face  restrictions  in  accessing the IBCLC credentials and gaining employmenent literature, also reveals the need for further work to ensure interventions are culturally competent and delivered equitably to support sustained breastfeeding for Black women.\n\nThis study reveals the need for further work  to  ensure  interventions  designed  to  improve  breast-feeding are culturally competent and delivered equitably to support sustained breastfeeding for Black women."]
["Application of Kotter's Theory of Chnage to Achieve Baby-Friendly Designation","Nursing for Women's Health","Henry, L. S., M. Christine Hansson, V. C. Haughton, A. L. Waite, M. Bowers, V. Siegrist, and E. J. Thompson. “Application of Kotter’s Theory of Change to Achieve Baby-Friendly Designation.” Nurs Womens Health 21, no. 5 (2017): 372–82. https://doi.org/10.1016/j.nwh.2017.07.007.",2017,"United States","Hospital","Becoming/pre BFHI","Health workers","To descrbe the process of BFHI accreditation, through the application of Kotters Theory of Change.  ","First survey: full achievement occurred for only 2 of the 10 steps to successful breastfeeding; the remaining 8 were only partially met.\n\nThere was a disparity between knowledge and practice. Most important, mothers had difficulty validating that staff adequately showed BFHI expecta-tions and standards.\n\nThe results of the first survey became a call to action that the gap between staff  knowledge and behavior and the actual experience of mothers had to close. In short, the culture needed to change. \n\nKotter's Change Model and its eight steps aligned best with the approach needed going forward.\n\nTo successfully achieve BFHI designation on our second survey, a cultural transformation needed to occur. Kotter's change principles provided the impetus and structure to accomplish the necessary modification in attitudes and behaviors.\n\nSpecific strategies used in the inpatient and outpatient settings transformed maternity, obstetric, and pediatric practices. \n\nImproved use of community support groups aids in maintaining breast milk as the primary nutrition for newborns after hospital discharge. \n\nSustaining a BFHI designation remains a 'work in progress', one that nursing leaders are committed to ensuring. \nAs the nursing department prepares for anticipated BFHI adoption in the NICU, Kotter's model will be instrumental in effectively changing the culture in this new arena. "]
["Barriers and Strategies for Successful Implementation of Baby-Friendly Hospital Initiative: A Scoping Review","Clinical lactation","Hirani, Shela Akbar Ali, and Reihaneh Ahmadi. “Barriers and Strategies for Successful Implementation of Baby-Friendly Hospital Initiative: A Scoping Review.” Clinical Lactation 13, no. 3 (2022): 139–55. https://doi.org/10.1891/CL-2022-0003.",2022,"Global scoping review","Hospital","BHFI overall/all steps ","Academic - scoping review"," to identify challenges that hinder the successful implementation of BFHI and explore strategies to overcome those barriers to promote, protect and support breastfeeding practices of mothers all over the world","The barriers to the successful implementation of the BFHI include the absence of clearly stated policies on breastfeeding, lack of uniform understanding of BFHI, insufficient support and resources, disagreements/lack of collaboration among health care professionals, maternal circumstances, and hospital routines and practices. "]
["Is Baby-Friendly Breastfeeding Support in Maternity Hospitals Associated with Breastfeeding Satisfaction Among Japanese Mothers?","Maternal and Child Health Journal","Hongo, H., K. Nanishi, A. Shibanuma, and M. Jimba. “Is Baby-Friendly Breastfeeding Support in Maternity Hospitals Associated with Breastfeeding Satisfaction among Japanese Mothers?” Matern Child Health J 19, no. 6 (2015): 1252–62. https://doi.org/10.1007/s10995-014-1631-8.",2015,"Japan","Hospital & Community","BHFI overall/all steps ","Postpartum women","This study  examined whether  babyfriendly  breastfeeding  support was  associated  with  breastfeeding  satisfaction, duration, and  exclusivity among Japanese mothers","- Mothers  who  experienced  early  skin-to-skin  contact  with their  infants were  more likely to report breastfeeding  satisfaction than those who did not. \n- Among mothers without exclusive    breastfeeding  intention,    those    who    were encouraged  to  feed  on  demand  were  more  likely  to  be breastfeeding without formula at 1 month and to perceive breastfeeding as beneficial for  their  baby   than  those  who  were  not  so  encouraged.\n- Breastfeeding satisfaction was a useful measure of breast-feeding  outcome. \n-  Early  skin-to-skin  contact  and  encour-agement   to   feed   on   demand   in   the   hospital facilitate breastfeeding satisfaction"]
["The Baby-Friendly Hospital Initiative as an Intervention to Improve Breastfeeding Rates: A Review of the Literature","Journal of Midwifery and Women's Health ","Howe-Heyman, A., and M. Lutenbacher. “The Baby-Friendly Hospital Initiative as an Intervention to Improve Breastfeeding Rates: A Review of the Literature.” J Midwifery Womens Health 61, no. 1 (2016): 77–102. https://doi.org/10.1111/jmwh.12376.",2016,"United States","Hospital","BHFI overall/all steps ","Health workers and postpartum women and their babies ","The purpose of this review was to evaluate the literature and synthesize findings to determinethe effectiveness of the BFHI as an intervention to improve breastfeeding initiation, duration, and exclusivity","- When taken as a whole, the majority of research included for review supports the BFHI as an intervention to increase breastfeeding initiation, long-term breastfeeding duration,and increased breastfeeding exclusivity rates. \n- Most research did not support the BFHI as an intervention that improves short-term breastfeeding duration rates. \n- There is only a small difference in the number of studies showing that the BFHI increases breast-feeding initiation rates and those showing that it does not have an effect on initiation (4 vs 3, respectively).\n-  7 studies specifically measured breastfeeding initiationas an outcome. Among them, 4 found a statistically signif-icant increase in breastfeeding initiation after implementa-tion of the BFHI."]
["The effects of Baby Friendly Initiative trainingon breastfeeding rates and the breastfeeding attitudes, knowledge and self-efficacy of community health-care staff","Primary Health Care Research & Development ","Ingram, J., D. Johnson, and L. Condon. “The Effects of Baby Friendly Initiative Training on Breastfeeding Rates and the Breastfeeding Attitudes, Knowledge and Self-Efficacy of Community Health-Care Staff.” Prim Health Care Res Dev 12, no. 3 (2011): 266–75. https://doi.org/10.1017/s1463423610000423.",2011,"UK","Hospital","BHFI overall/all steps ","Health workers","To evaluate the effects of Baby Friendly Initiative (BFI) community training on breastfeeding rates, staff and mothers in a large Primary Care Trust. ","- Breastfeeding rates at eightweeks increased significantly, and a baby born in 2009 was 1.57 times more likely to be breastfed than one born in 2006. \n- Statistically significant improvements in staffbreastfeeding attitudes, knowledge and self-efficacy were seen after attending thecourse, in addition to increases in the appropriate management of breastfeeding problems. \n-The response to the course was overwhelmingly positive and felt to be extremely worthwhile. It has led to renewed enthusiasm, improved the consistency of advice among team members and raisedconfidence levels of all staff who help mothers with breastfeeding. \n-Health visitors felt confident about enabling nursery nurses to take a greater role in breastfeeding sup-port. \n- A small survey of mothers reported increases in exclusive breastfeeding and signs of increased breastfeeding self-efficacy"]
["Postpartumhood: Dietary Practices and Breastfeeding Attitudes among Malays","SOCIAL SCIENCES & HUMANITIES","Jamaludin, Shariffah Suraya Syed, and Maria Aloysius. “Postpartumhood: Dietary Practices and Breastfeeding Attitudes among Malays.” Pertanika Journal of Social Science and Humanities 25 (2017): 153–62.",2017,"Malaysia","Hospital","BHFI overall/all steps ","Postpartum women","This paper explores mothers perception of food served in the maternity ward of government hospitals, perception of breastfeeding in public and its relation to postpartum wellness, and the role of Baby Friendly Hospital Initiatives (BFHI) in the promotion of breastfeeding. ","The mothers agreed government hospitals are baby friendly hospitals with written policies on breastfeeding. Nurses promote the benefits of breastfeeding and initiate breastfeeding about half an hour after delivery. Respondents of this study claimed that the hospital does not really practice in-rooming. Babies were brought to their mothers for breastfeeding; the staff use formula milk to feed infants when they are experiencing health issues. Mothers agreed that the hospital staff and nurses educate them on breastfeeding techniques. Breastfeeding on demand is highly supported by nurses as infants are brought to their mothers during feeding time. Artificial pacifiers are not provided. Breastfeeding support groups in the hospitals though are available for first time mothers, the respondents claim they are unaware of their existence."]
["Breastfeeding Outcomes Among WIC-Participating Infants and Their Relationships to Baby-Friendly Hospital Practices","BREASTFEEDING MEDICINE","Jung, S., T. Z. Nobari, and S. E. Whaley. “Breastfeeding Outcomes Among WIC-Participating Infants and Their Relationships to Baby-Friendly Hospital Practices.” Breastfeed Med 14, no. 6 (2019): 424–31. https://doi.org/10.1089/bfm.2019.0004.",2019,"United States","Hospital","BHFI overall/all steps ","Newborns and postpartum women","This studyexamines  changes  in  Baby-Friendly  hospital  practices,  breastfeeding  outcomes,  and  their  relationships  with Baby-Friendly hospital status among WIC-enrolled children in LAC. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a federally funded  nutrition  program for  low-income pregnant, breastfeeding, and postpartum women, infants, and children under 5 who are at risk for poor nutrition, provides breast-feeding support, nutrition education, and food assistance.","In 2017, mothers surveyed were more likely to engage in Baby-Friendly hospital practices compared with 2008. Any and exclusive breastfeeding outcomes at 1 and 3 months significantly increased since 2014, andbreastfed infants were more likely to have mothers who participated in Baby-Friendly hospital practices. The more Baby-Friendly hospital practices mothers met, the better the breastfeeding outcomes. However, there is room for improvement in the uptake of Baby-Friendly hospital practices in Baby-Friendly hospitals.\n\nTo examine the impact of Baby-Friendly hospital practices on  breastfeeding  duration,  we  ran  multivariate  logistic  regressions, controlling for factors known to be associated with breastfeeding duration. Table 3 shows that for any and ex-clusive breastfeeding outcomes, the odds of an infant being breastfed were significantly higher when the infant's mother received at least two Baby-Friendly hospital practices that we evaluated. The mother's intention to breastfeed was another strong,  significant  predictor of any breastfeeding duration and  exclusive  breastfeeding  at  1  month.  Having  a  father living in the household was significantly associated with any and exclusive breastfeeding at 1 month. Children born pre-term  were  significantly  less  likely  to  receive  any  breast-feeding at 1 month, and less likely to be exclusively breastfed at 1 and 3 months compared with children who were not born preterm."]
["Key Program Findings and Insights From the Baby-Friendly Hawaii Project","Journal of Human Lactation","Kahin, S. A., M. McGurk, H. Hansen-Smith, M. West, R. Li, and C. L. Melcher. “Key Program Findings and Insights From the Baby-Friendly Hawaii Project.” J Hum Lact 33, no. 2 (2017): 409–14. https://doi.org/10.1177/0890334416683675.",2017,"United States","Hospital","Becoming/pre BFHI","Hospitals","We examined the BFHP's final evaluation report and Hawaii breastfeeding and maternity care data to identify the role of the BFHP in facilitating improvements in maternity care practices and breastfeeding rates","Since 2010, 52 hospital site visits, 58 trainings, and ongoing technical assistance were administered, and more than 750 staff and health professionals from BFHP hospitals were trained. Hawaii's overall quality composite Maternity Practices in Infant Nutrition and Care score increased from 65 (out of 100) in 2009 to 76 in 2011 and 80 in 2013, and Newborn Screening Data showed an increase in statewide exclusive breastfeeding from 59.7% in 2009 to 77.0% in 2014.\n\nAlthough the BFHP did not require hospitals to become Baby-Friendly, several hospitals took steps toward designation. As of February 26, 2016, four hospitals had registered with Baby-Friendly USA's 4-D Pathway to designation, and three of the four completed a mock Baby-Friendly visit with the project consultant. Of these four hospitals, three had their designation assessments and received Baby-Friendly designation"]
["Hospital breastfeeding support and exclusive breastfeeding by maternal prepregnancy body mass index","Maternal and Child Nutrition","Kair, L. R., N. C. Nickel, K. Jones, K. Kornfeind, and H. L. Sipsma. “Hospital Breastfeeding Support and Exclusive Breastfeeding by Maternal Prepregnancy Body Mass Index.” Matern Child Nutr 15, no. 3 (2019): e12783. https://doi.org/10.1111/mcn.12783.",2019,"United States","Hospital","Steps 4-10 ","Postpartum women","We sought to determine whether pre-pregnancy BMI is associated with the implementation andeffectiveness of the Ten Steps. ","Results suggest that two practices (i.e., holding their babies skin\u0090to\u0090skin for the first time and being encouraged to breastfeed on demand) were more strongly associated with exclusive breastfeeding among motherswith obesity than other mothers. Additionally, mothers with obesity reported holding babies skin to skin significantly less often than other mothers. "]
["Awareness about â€œTen Steps for Successful Breastfeedingâ€\u009d among Medical and Nursing Students","International Journal of Preventive Medicine","Kakrani, Vandana A., Hetal K. Rathod, Megha S. Mammulwar, and Jitendra S. Bhawalkar. “Awareness about ‘Ten Steps for Successful Breastfeeding’ among Medical and Nursing Students.” International Journal of Preventive Medicine 6 (2015). https://doi.org/10.4103/2008-7802.156838.",2015,"India","Hospital","BHFI overall/all steps ","Health workers","To know the extent of knowledge of students about BFHI along with its understanding and to find out the gap in their knowledge about BFHI steps.","Atotal of 102(51.6%) medical and 96(48.4%) nursing students comprising of 57(28.8%) males and 141(71.2%) females were interviewed, had similar mean score about the ten steps of BFHI. Female respondents 82.3% had best understood the step 2(training), as compared to males 80.7%. About step 6(no supplements) 94.3% females and 86% males had well understood the step. Step 7(rooming in) was known to 85.8% females and 54.4% males respectively. Step 9(no pacifiers) was known to 80.1% females while among males 56.1% were aware. There was statistically significant difference in their knowledge about the steps 2 and 4(skin to skin), 5(counseling), 7, and 9 as females were more aware about these steps than males. The least understood steps in medical and nursing students were step 1(written policy)(15.7%, 15.6%), step 3(prenatal education)(27.5%, 29.2%), step 8(cues)(10.8%, 24%) and step ten(community support)(8.8%, 11.5%) respectively"]
["Knowledge effect on postnatal mothers regarding Baby Friendly Hospital Initiative","INTERNATIONAL JOURNAL OF RESEARCH IN PHARMACEUTICAL SCIENCES","Kalabarathi, S., and A. Aarthi. “Knowledge Effect on Postnatal Mothers Regarding Baby Friendly Hospital Initiative.” International Journal of Research in Pharmaceutical Sciences 11, no. Special Issue 4 (2020): 300–303. https://doi.org/10.26452/ijrps.v11iSPL4.3789.",2020,"India","Hospital","BHFI overall/all steps ","Postpartum women","The purpose of the study [1] to assess the existing level of knowledge on baby friendly hospital initiative among postnatal mothers.[2] to evaluate the\neffectiveness of an information booklet on knowledge of baby friendly hospital initiative among postnatal mothers.[3] to find out association between knowledge of postnatal mothers regarding baby friendly hospital initiative with selected socio demographical variables.\n","6 (10%) had adequate, 9 (15%) had moderate adequate knowledge and also 45 (75%) had inadequate knowledge in pretest and 42( 70%) had adequate, 12 (20%) had moderate adequate knowledge and 6 (10%) had inadequate knowledge in posttest and concluded that there was a significant improvement after administration of information booklet. Thus, information booklet was effective in improving the knowledge on Baby Friendly Hospital initiative among postnatal mothers."]
["Breastfeeding perceptions in communities in Mangochi district in Malawi","Acta Paediatrica","Kamudoni, P. R., K. Maleta, Z. Shi, M. M. de Paoli, and G. Holmboe-Ottesen. “Breastfeeding Perceptions in Communities in Mangochi District in Malawi.” Acta Paediatr 99, no. 3 (2010): 367–72. https://doi.org/10.1111/j.1651-2227.2009.01603.x.",2010,"Malawi","Community ","BHFI overall/all steps ","Newborns and postpartum women","To investigate mothers perceptions of breastfeeding and influences from their social network.","The opinion that exclusive breastfeeding should last for 6 months was also independently associated with giving birth at a Baby-Friendly health facility. A likely explanation could be that mothers who had given birth in the Baby-Friendly facility, Mangochi District Hospital, had access to more comprehensive information on recommended breast-feeding practices, unlike those who had delivered at the rural primary health care unit, Lungwena Health Centre, which at the time of the study was not designated as Baby-Friendly. In the light of this understanding, this is particularly an important finding for Mangochi district hospital and the Malawi Ministry of Health as it demonstrates the positive impact of the work of health workers when they attain a Baby-Friendly status, and the far reaching impact of the resources being allocated to the BFHI."]
["Bringing Baby-Friendly to the Indian Health Service: A Systemwide Approach to Implementation","Journal of Human Lactation","Karol, S., T. Tah, C. Kenon, J. Meyer, J. Yazzie, C. Stephens, and A. Merewood. “Bringing Baby-Friendly to the Indian Health Service: A Systemwide Approach to Implementation.” J Hum Lact 32, no. 2 (2016): 369–72. https://doi.org/10.1177/0890334415617751.",2016,"United States","Hospital","Becoming/pre BFHI","Hospitals","Aim: Describes the systemwide approach to BFHI implementation within the [Native American] Indian Health Service. ","The IHS [US Department of Health and Human Services Indian Health Service] implemented the BFHI across 100% of federal sites in approximately 3 years. This was achieved by a combination of HQ leadership directive, regionally administered outreach and technical assistance from the area level, and quality improvement and detail-oriented change by each hospital. \n\nThe IHS serves a disadvantaged, impoverished population with high medical need, often in geographically remote areas. Whereas average per capita health care spending in the US is $7329, the IHS budget is funded at just $2643 per person per year. As an overburdened, underfunded system, the IHS faces tremendous staffing and operational challenges on an ongoing basis. In addition, hospitals encoun-tered barriers common to non-IHS hospitals, such as initial lack of physician buy-in, and resistance to change.\n\nCertain aspects innate to the IHS contributed to this success. Status as a government agency led to early, universal compli-ance with the Code, with which many private hospitals strug-gle. The IHS used its well-established distance learning techniques and information technology to communicate effectively with remote facilities. Sharing practical resources, successes, and challenges across a mission-driven system transcended geographic collaborative norms. Hospital employees reached out to help other facilities with hands-on help and advice, fostering a broad team spirit and collaborative effort. In addition, the relatively small size of IHS facilities meant that the system had relatively few employees to train, although almost all facilities went beyond the BFHI training requirements and some trained all nursing staff and physicians. Once 50% of sites had become designated, peer pressure and expectations also played into the equation."]
["Hospital infant feeding practices in metropolitan Chicago: An evaluation of five of the â€˜Ten steps to successful breast-feedingâ€™","Journal of the Academy of Nutrition and Dietetics","Karra, M. V., K. G. Auerbach, L. Olson, and E. P. Binghay. “Hospital Infant Feeding Practices in Metropolitan Chicago: An Evaluation of Five of the ‘Ten Steps to Successful Breast-Feeding.’” Journal of the American Dietetic Association 93, no. 12 (1993): 1437–39. https://doi.org/10.1016/0002-8223(93)92248-V.",1993,"United States","Hospital","5 of the 10 BFHI steps","Health workers","This study shares the outcomes of  an evaluation of five of the ‘Ten Steps to Successful Breast-Feeding' at a Hospital in Metropolitan Chicago. \nAfter the implementation of the BFHI, the initiative provides an opportunity for hospitals worldwide to engage in both self-evaluation and assessment by consultants to determine how completely these institutions promote, protect, and support breast-feeding.","25 respondents actively encourage BF, 16 recommend, 1 recommeded bottle feeding - Reasons for not reccommending BF related to mothers use of drugs and medications. - 42 indicated that their hospitals offered rooming-in; 24 said their hopsitals had written rooming in policy. - Many staff members at the same hospital either disagreed that a policy to support BF practice was in place or did not know if the policy was in place.\nLack of consistent information between nutrition educators and hospital staff who serve the same patient population may confuse rather than elighten.\n"]
["Maternal awareness of breastfeeding policies in babyâ€\u0090friendly hospitals in Jordan","Nursing Forum","Kasem, Abedallah, Sawsan Abuhammad, and Etab M. S. Alswaiti. “Maternal Awareness of Breastfeeding Policies in Baby‐friendly Hospitals in Jordan.” Nursing Forum 57, no. 5 (2022): 843–50. https://doi.org/10.1111/nuf.12731.",2022,"Jordan","Hospital","BHFI overall/all steps ","Postpartum women","to investigate the maternal perception and awareness of Baby-Friendly Hospital Initiative (BFHI) policies","Mothers had moderate levels of awareness of breastfeeding importance; further, most of them mentioned the provision of a policy that addresses all thesteps to successful breastfeeding as a major facilitator to breastfeeding. In terms ofthe BFHI, mothers had a moderate level of awareness of breastfeeding initiativesand showed positive perceptions of BFHI policies.\n\nLow awareness of the availability of health education centers that aid mothers to learn strategies to prevent disease during breastfeeding is alarming. These areas are significant steps that cannot be overlooked because some diseases and some medications required to treat those diseases can impede the ability ofmothers to breastfeed their babies, because medications can transfer via breast milk from mother to child.\nWithout resolving existing barriers mothers will find it difficult to performbreastfeeding and sustain it, even in the presence of facilitators and even with the knowledge and awareness that breastfeeding is beneficial for their babies.\n\nPossessing a bachelor's degree and receiving antenatal care in an agency were found to increase the level of maternal awareness. The rest of the predictor variables (living in villages, possessing a basic level of education,number of breastfeeding times per day, and being unemployed) had an inverse relationship with maternal awareness."]
["Babyâ€\u0090Friendly Community Initiativeâ€”From national guidelines to implementation: A multisectoral platform for improving infant and young child feeding practices and integrated health services","Maternal and Child Nutrition","Kavle, J. A., B. Ahoya, L. Kiige, R. Mwando, F. Olwenyi, S. Straubinger, and C. M. Gathi. “Baby-Friendly Community Initiative-From National Guidelines to Implementation: A Multisectoral Platform for Improving Infant and Young Child Feeding Practices and Integrated Health Services.” Matern Child Nutr 15 Suppl 1, no. Suppl 1 (2019): e12747. https://doi.org/10.1111/mcn.12747.",2019,"Kenya","Community ","BFCI only  ","Newborn/infants 12 months of age","To describe the process of implementation of BFCI within the health system in Kenya\nTo discuss successes, challenges, and lessons learned on BFCI inthe country.\nTo discuss opportunities for integration of BFCI into other healthareas and sectors. \nTo discuss the future and next steps for BFCI in Kenya.","In Maternal and Child Survival Program (MCSP) and UNICEF areas, 685 community leaders were oriented to BFCI, 475 health providers trained, 249 sup-port groups established, and 3,065 children 0-12 months of age reached (MCSP only).Though difficult to attribute to our programme, improvements in infant and young childfeeding practices were observed from routine health data following the programme,with dramatic declines in prelacteal feeding (19% to 11%) in Kisumu County and(37.6% to 5.1%) in Migori County from 2016 to 2017. Improvements in initiation andexclusive breastfeeding in Migori were also noted from 85.9% to 89.3% and 75.2%to 92.3%, respectively. Large gains in consumption of iron rich complementary foodswere also seen (69.6% to 90.0% in Migori, 78% to 90.9% in Kisumu) as well as introduc-tion of complementary foods (42.0-83.3% in Migori). Coverage for BFCI activities var-ied across counties, from 20% to 60% throughout programme implementation andwere largely sustained 3 months postimplementation in Migori, whereas coveragedeclined in Kisumu. BFCI is a promising platform to integrate into other sectors, suchas early child development, agriculture, and water, sanitation, and hygiene.\n\nKey achievements are the orientation of 44 national stakeholdersand from MCSP and UNICEF areas, BFCI orientation for 685 community leaders, BFCI training for 475 health providers and 776community members/volunteers, establishment of 249 mother tomother/community support groups, and the establishment of 11 breastfeeding corners in five counties. In MCSP-supported areas, theproject reached 3,065 children, where data were collected on children, 12 months of age."]
["The revitalization and scaleâ€\u0090up of the Babyâ€\u0090Friendly Hospital Initiative in Malawi","Maternal and Child Nutrition","Kavle, J. A., P. R. Welch, F. Bwanali, K. Nyambo, J. Guta, N. Mapongo, S. Straubinger, and S. Kambale. “The Revitalization and Scale-up of the Baby-Friendly Hospital Initiative in Malawi.” Matern Child Nutr 15 Suppl 1, no. Suppl 1 (2019): e12724. https://doi.org/10.1111/mcn.12724.",2019,"Malawi","Hospital","BHFI overall/all steps ","Health facility level","The objectives of this paper are to (a) discuss the revitalizationand scale\u0090up process of BFHI in Malawi at the community, district,and national levels; (b) describe successes, challenges, and lessons learned from the revitalization and scaleâ€\u0090up of BFHI in Malawi; and(c) describe next steps and the future of BFHI in Malawi.","More than 80,000 mothers received counselling on exclusive breastfeeding following childbirth prior to discharge from the health facility. Early initiation of breastfeeding was tracked quarterly from baseline through endline via routine MOH health facility data. Increases in early initiation of breastfeeding were seen in two of the three regions of Malawi: by 2% in the Central region and 6% in the Southernregion. "]
["Effects of baby-friendly hospital initiative on breast-feeding practices in Sindh","J Pak Med Asso","Khan, M., and D. S. Akram. “Effects of Baby-Friendly Hospital Initiative on Breast-Feeding Practices in Sindh.” J Pak Med Assoc 63, no. 6 (2013): 756–59.",2013,"Pakistan","Hospital","BHFI overall/all steps ","Postpartum women","To determine changes in the breastfeeding practices of mothers after receiving counseling on 'Ten Steps to Successful Breastfeeding' as defined by the Baby Friendly Hospital Initiative comparing baby friendly hospitals(BFHs) and non-baby-friendly hospitals in Sindh, Pakistan.\n\nThe  objective  of  the  study  was  to  evaluate implementation of the '10 Steps to Successful Breastfeeding' enforced by BFHI in 53 certified BFHs of Sindh. The interviewsfrom BFHs and the NBFHs were compared to determine the effects on breastfeeding practices in the province.","In BFH, 189 (96.4%) and in NBFH 1 (2.5%) listed more thantwo  benefits  of  breastfeeding.  \n\nBesides,  165  (94.5%) mothers were given help by healthcare providers in BFHs and 5 (12.5%) in NBFH were helped by family members.\n\nThe skill development for position and attachment was187 (95.4%) in BFHs and 32 (80%) in NBFHs. \n\nImportance ofrooming-in was known by 187 (95.2%) in BFHs and 3 (7.5%)  in  NBFHs.  The  importance  of  demand  feeding  was 194 (98.97%) in BFH compared to 12 (30%) in NBFH (Table-2). \n\nThe skill development in breastfeeding practices was188 (95.9%) in BFHs, and 14(3.5%) in NBFHs. \n\nThe group talk about  infant-feeding  formula  was  not  discussed  in178 (90.08%) in BFH and 14 (35%) in NBFH. \n\nThere was an increase in the breastfeeding practice up to 194 (98.97 %)in BFHs compared to 12 (30 %) in NBFHs."]
["Effectiveness of the baby-friendly community initiative onexclusive breastfeeding in Kenya","Maternal and child nutrition","Kimani‐Murage, Elizabeth W., Judith Kimiywe, Antonina N. Mutoro, Calistus Wilunda, Frederick Murunga Wekesah, Peter Muriuki, Bonaventure M. Mwangi, et al. “Effectiveness of the Baby‐friendly Community Initiative on Exclusive Breastfeeding in Kenya.” Maternal & Child Nutrition 17, no. 3 (2021): 1–11. https://doi.org/10.1111/mcn.13142.",2021,"Kenya","Community ","BFCI only  ","Postpartum women","We tested the effectiveness of the baby-friendly community initiative (BFCI) on EBF in rural Kenya.","Compared with chil-dren in the control group, children in the intervention group were more likely toexclusively breastfeed for 6 months (79.2% vs. 54.5%; P< .05). Children in the inter-vention group were also exclusively breastfed for a longer time, mean difference (95% confidence interval [CI]) 0.62 months (0.38, 0.85; P< .001). \n\nAn obstacle to scaling, which could exist, relates tothe need for CHVs to be compensated for their work. In this study,we provided a small-scale start-up resource for IGAs to support theprogramme locally at the request of the community. \n\nThe community-based structure, which included active involvement of families and the community, ensured motherswere supported and encouraged to exclusively breastfeed. We also had assured continuum of care because of strong linkages between the community and health facilities. "]
["Improved breastfeeding duration with Baby Friendly Hospital Initiative implementation in a diverse and underserved population","Birth","Kivlighan, K. T., C. Murray-Krezan, T. Schwartz, G. Shuster, and K. Cox. “Improved Breastfeeding Duration with Baby Friendly Hospital Initiative Implementation in a Diverse and Underserved Population.” Birth 47, no. 1 (2020): 135–43. https://doi.org/10.1111/birt.12468.",2020,"United States","Hospital","Steps 4-9","Postpartum women","To evaluate the impact of transition to Baby Friendly certification on underserved populations in the United States, we undertook this retrospective cohort study in New Mexico, a large southwestern state with a diverse, rural population and limited access to health care. Our purpose was twofold: (a) to evaluate the impact of BFHI implementation on the short-term duration of both any breastfeeding and exclusive breastfeeding, and (b) to determine the impact of exposure to the inpatient Ten Steps on short-term breastfeeding duration, both individually and cumulatively","Maternal age, parity, and unplanned readmission were sig-nificant covariates in the logistic regression model com-paring any breastfeeding to formula feeding (Table 3). Of note, older mothers and primiparae were more likely to be breastfeeding at 2-6 weeks postpartum. \n\nEighty-three percent of mother-infant pairs in the post-BFHI cohort reported any breastfeeding at 2-6 weeks postpartum compared with 72% in the pre-BFHI cohort.\n\nMaternal age, ethnicity, race, parity, insurance type, and unplanned hospital readmissions were significant covariates in the logistic regression model comparing exclusive breast-feeding to any formula (Table 3). In particular, Hispanic women, uninsured women, and persons of color were less likely to be breastfeeding at 2-6  weeks postpartum. \n\nOf the mother-infant pairs, 69% in the post-BFHI cohort reported exclusive breastfeeding at 2-6 weeks postpartum as compared to 58% in the pre-BFHI cohort. Therefore, implementation of the BFHI interventions was associated with increased short-term duration rates of any breastfeeding and exclusive breastfeeding at 2-6  weeks postpartum.\n\nMother-infant pairs doing any breastfeeding at 2-6  weeks postpartum were exposed to a mean of 5.7 of the six inpatient Ten Steps on average. In comparison, those formula feeding only at 2-6 weeks were exposed to a mean of 5.3  of the six inpatient Ten Steps on average. \n\nWith each additional exposure to one of the inpatient Ten Steps, the odds of any breastfeeding increased by 81% (OR 1.81, 95% CI  =  1.32-2.50) controlling for maternal age and parity (Table 4). Therefore, exposure to all six inpatient Ten Steps increased the odds of any breastfeeding by 34 times compared with no exposure. Similar exposures  were found for exclusively breastfeeding mother-infant pairs, as compared to those giving any for-mula at 2-6 weeks postpartum. \n\nEach additional exposure to an inpatient in-tervention (Steps 4-9) increased the likelihood of exclusive breastfeeding by 70%, controlling for maternal age, parity, and unexpected hos-pital readmission. \n\nExposure to all six inpatient Ten Steps increased the odds of exclusive breastfeeding by 24 times compared with no exposure. Therefore, cumulative ex-posure to the inpatient Ten Steps was associated with in-creased short-term duration of both any breastfeeding and exclusive breastfeeding (Table 4).\n\nSteps 5, 6, 8, and 9 were experienced by >92% of all partici-pants, whereas Steps 4 and 7 were experienced by 87% and 89%, respectively. Exposure to inpatient Step 9 (give no pacifiers or artificial nipples to breastfeeding infant's uniquely increased the likelihood of any breastfeeding at 2-6 weeks postpartum by 5.7 times after controlling for maternal age, parity, and 1-minute Apgar score (Table 5).\n\nStep 6 (give infants no food or drink other than breast-milk, unless medically indicated) had a unique impact on the rate of exclusive breastfeeding at 2-6  weeks postpartum. Mother-infant pairs exposed to this intervention were 4.4 times more likely to be exclusively breastfeeding at 2-6 weeks postpartum as compared to formula feeding only. Maternal age, parity, unplanned readmission, and NICU admission were associated with the outcome and were controlled in the model. "]
["Providing Equitable Postpartum Breastfeeding Support at an Urban Academic Hospital","AWHONN","Knutson, J., and J. Butler. “Providing Equitable Postpartum Breastfeeding Support at an Urban Academic Hospital.” Nurs Womens Health 26, no. 3 (2022): 184–93. https://doi.org/10.1016/j.nwh.2022.03.002.",2022,"United States","Hospital","BHFI overall/all steps ","Postpartum women","to evaluate intervention effects over time according to Institute for Healthcare Improvement criteria, and outcome data informed tests of change for subsequent cycles. With this project, we aimed to increase exclusive breast-feeding at hospital dischargeamong clients receiving careby an OB/GYN resident service by 20% over 8 weeksthrough equitable implementation of Baby-Friendly interventions.","Rates of exclusive breastfeeding at hospital discharge were 7% at baseline and 13% after implementation. Rates ofexclusive breastfeeding among Black clients were 0% atbaseline and 16% after implementation. Clients demonstrated Baby-Friendly knowledge (teach-back average, 89%) butcontinued to supplement with formula, most often related to supply concerns (65%).\n\nIntentionally equitable implementation of the Baby-Friendly steps may ameliorate racial disparities in breastfeedingduring the early postpartum period. Preparing families to exclusively breastfeed should begin prenatally."]
["A 5-Year Follow-up Study of Hospital Breastfeeding Policies in the Philadelphia Area: A Comparison With the Ten Steps","Journal of Human Lactation","Kovach, A. C. “A 5-Year Follow-up Study of Hospital Breastfeeding Policies in the Philadelphia Area: A Comparison with the Ten Steps.” J Hum Lact 18, no. 2 (2002): 144–54. https://doi.org/10.1177/089033440201800206.",2002,"United States","Hospital","BHFI overall/all steps ","Hospital-level,  health workers","The purpose of this study was to describe the current status of hospital breastfeeding policies and practices in the Philadelphia area, to assess hospitals' current implementation levels of theTen Steps to Successful Breastfeeding, and to compare current implementation levels with 1994 baseline data. ","Most surveyed hospitals were fully implementing 5 of the Ten Steps.Thirty-seven percent of the hospitals were classified as high implementers and 63% as partial implementers of the Ten Steps overall. \n\nThe  shift  from  written  breastfeeding  and  infant-feeding protocols to formal signed breastfeeding policies  in  most  maternity  units  has  positively  affected breastfeeding  promotion  efforts  in  the  Philadelphiaarea.\n\nInterviewees at several hospitals commented that having signed policies in place has helped them to set goals and facilitate change.\n\nTo address the cultural diversity in many city hospitals, a study of new mothers is under way exploring where mothers receive breastfeeding  information pre-natally,  their  social  support  structure, and experiences delivering in the hospital setting."]
["Hospital Breastfeeding Policies in the Philadelphia Area: A Comparison with the Ten Steps to Successful Breastfeeding","BIRTH","Kovach, A. C.“Hospital Breastfeeding Policies in the Philadelphia Area: A Comparison with the Ten Steps to Successful Breastfeeding.” Birth 24, no. 1 (1997): 41–48. https://doi.org/10.1111/j.1523-536x.1997.tb00335.x.",1993,"United States","Hospital","BHFI overall/all steps ","Health workers","The purpose of this  study was to describe  the current status of hospital breastfeeding policies and practices in the southeastern Pennsylvania Delaware Valley and  the  degree to which  the  hospitals  are  implementing  the  WHO/UNICEF Ten Steps to Successful  Breastfeeding","Most surveyed hospitals were implementing four of the steps and partially implementing  the  remaining six. Thirty-seven percent of the surveyed  hospitals  were classified as high implementers and 63 percent as partial implementers of the Ten Steps overall. Key issues that affect implementation of each step  were identified through in-depth discussion of several questions. \n\nWhen hospitals were classified by their overall level of implementation of the Ten Steps,  1 (3%) hospital was classified as ahigh implementer, 13 (34%) were classified as moder- ately high implementers,  22  (58%)  as  partial imple- menters, and  2 (5%) as low implementers. Most hospitals  were  classified  as  high  or  moderately  high implementers for four of the Ten Steps: printed information distributed to  breastfeeding mothers (Step 3) (38/100%); oral  breastfeeding instruction given to mothers  (Step 5) (2366%); infant feeding  schedules (Step 8) (34/90%);  and  hospital discharge  practices (Step 10) (22/58%).  The remaining steps, including key practices such as breastfeeding initiation, rooming- in, and  supplementation, were partially  implemented by most  study hospitals."]
["Breastfeeding and Infant Growth: Biology or Bias?","Paediatrics","Kramer, M. S., T. Guo, R. W. Platt, S. Shapiro, J. P. Collet, B. Chalmers, E. Hodnett, Z. Sevkovskaya, I. Dzikovich, and I. Vanilovich. “Breastfeeding and Infant Growth: Biology or Bias?” Pediatrics 110, no. 2 Pt 1 (2002): 343–47. https://doi.org/10.1542/peds.110.2.343.",2002,"Republic of Belarus","Hospital","BHFI overall/all steps ","Newborns and postpartum women","Is  the  robust  association  between  prolonged,  ex-clusive  breastfeeding  and  reduced  growth  causal? Available evidence suggests that prolonged and exclusive breastfeeding is associated with  lower  infant  weight and length  by  6  to  12months of age. This evidence, however, is based on ob-servational  studies,  which  are  unable  to  separate  theeffects  of  feeding  mode  per  se  from  selection  bias,  re-verse causality, and the confounding effects of maternalattitudinal factors","Infants from the experimental sites were sig-nificantly more likely to be breastfed (to any degree) at 3,6,  9,  and  12  months  and  were  far  more  likely  to  beexclusively breastfed at 3 months (43.3% vs 6.4%). \n\nOur results offer no support to theprevailing   premise   that   prolonged   and   exclusivebreastfeeding  inexorably  leads  to  deficits  in  weightand length during the first year of life. Instead, ourresults  showing  faster  weight  and  length  gains  ininfants   exposed   to   the   experimental   interventionsupport the current WHO and UNICEF recommen-dations for prolonged and exclusive breastfeeding."]
["Global Baby-Friendly Hospital Initiative Monitoring Data: Update and Discussion","Breastfeeding Medicine","Labbok, M. H. “Global Baby-Friendly Hospital Initiative Monitoring Data: Update and Discussion.” Breastfeed Med 7 (2012): 210–22. https://doi.org/10.1089/bfm.2012.0066.",2012,"Global study,  multiple countries","198 countries, national level, reporting on hospitals","BHFI overall/all steps ","Academic study -country/ hospital level ","The  purpose  of  this study is to assess trends in the numbers facilities ever-designated Baby-Friendly, to consider uptake of the new WHO/UNICEF BFHI materials, and to consider implications for future breastfeeding support","Seventy countries reporting in 2010-2011 and the updates from an additional 61 reporting in 2006-2007(n=131, or 66% of the 198 countries) confirm that there are at least 21,328 ever-designated facilities. This is 27.5% of maternities worldwide: 8.5% of those in industrialized countries and 31% in less developed settings. In 2010,government committees were  reported by 18 countries, and 34 reported using the  new BFHI materials: 14 reported using the maternity care and 11 reported using the HIV materials"]
["Implementing the ten steps to successful breastfeeding in multiple hospitals serving low-wealth patients in the US: innovative research design and baseline findings","International Breastfeeding Journal","Labbok, M. H., E. C. Taylor, and N. C. Nickel. “Implementing the Ten Steps to Successful Breastfeeding in Multiple Hospitals Serving Low-Wealth Patients in the US: Innovative Research Design and Baseline Findings.” Int Breastfeed J 8, no. 1 (2013): 5. https://doi.org/10.1186/1746-4358-8-5.",2013,"United States","Hospital","BHFI overall/all steps ","Health workers","This study explores implementation of the Ten Steps in hospitals that serve predominantly low wealth populations.","1) a universal lack of consistent breastfeeding records and statisticsfor regular monitoring/review, \n\n2) widespread misinterpretation of associated terminology, \n\n3) health care providers' reported practices not necessarily reflective of their knowledge and attitudes, and \n\n4) specific steps were found to be associated with hospital breastfeeding rates. \n\nA comprehensive set of facilitators and obstacles to initiation of theTen Steps emerged, and hospital-specific practice change challenges were identified."]
["BREAST FEEDING POLICIES AND PRACTICES IN CANADIAN HOSPITALS PROVIDING MATERNITY CARE","Canadian Medical Association Journal","Levitt, C. A., J. Kaczorowski, L. Hanvey, D. Avard, and G. W. Chance. “Breast-Feeding Policies and Practices in Canadian Hospitals Providing Maternity Care.” Cmaj 155, no. 2 (1996): 181–88.",1993,"Canada","Hospital","BHFI overall/all steps ","Hospital representatives","To determine the extent to which policies and practices of Canadian hospitals providing maternity care are consistent with the World Health Organization (WHO)/UNICEF 10 Steps to Successful Breastfeeding, the WHO International Code of Marketing of Breast-Milk Substitutes and the WHO/UNICEF Baby Friendly Hospital Initiative.","Although 58.4% (296/507) of the respondents reported that their hospital had a written policy on breast-feeding, only 4.6% (21/454) reported having one that complied with all of the WHO/UNICEF steps surveyed. This figure dropped to 1.3% (6/453) when compliance with the WHO code (distribution of free samples of formula to formula-feeding and breast-feeding mothers) was added. Hospitals in Quebec and the Prairie provinces were significantly more likely than those in Ontario to give free samples of formula to both breast-feeding (OR 2.39 [95% confidence interval (CI) 1.39 to 4.09] and 20.22 [95% Cl 9.27 to 44.33] respectively) and formula-feeding mothers (OR 1.82 [95% Cl 1.07 to 3.1 1] and 8.03 [95% Cl 3.29 to 19.6] respectively), after adjustment for hospital size and university affiliation status."]
["Breastfeeding Policies and Practices in Canadian Hospitals: Comparing1993 with 2007","Birth","Levitt, C., L. Hanvey, J. Kaczorowski, B. Chalmers, M. Heaman, and S. Bartholomew. “Breastfeeding Policies and Practices in Canadian Hospitals: Comparing 1993 with 2007.” Birth 38, no. 3 (2011): 228–37. https://doi.org/10.1111/j.1523-536X.2011.00479.x.",2011,"Canada","Hospital","BHFI overall/all steps ","Health workers","The purpose of this study is to describe and compare maternity hospitals' adherence to the BFHI in1993  and  2007  for  Canada  and  for  each  province  and  territory.","Eighty-two percent  of  hospitals  in  1993  and  68  percent   in  2007  had  exclusive contracts with formula companies. \n\nFifty-eight percent of hospitals in 1993 and 90percent in 2007 never gave breastfeeding mothers sample packs containing formula.\n\nFifty-eight percent  in 1993 and 85 percent in 2007 had written breast-feeding  policies  (Step  1);  \n\n97  percent   in  1993  and  99  percent  in  2007 allowed mothers to breastfeed, on cue, whenever the babies indicated an interest 24 hours a day (Step 8); \n\n24 percent in 1993 and 64 percent in 2007 reported that they did not provide soothers (Step 9); \n\n58 percent in 1993 and 68 percent  in 2007 always offered information on breastfeeding support groups and  advice at time odischarge  (Step  10)\n\nNote: Although only 6 Canadian hospitals, 3 birthing  centers, and 13 community centers  have  been assessed as Baby-Friendly Hospitals (8), 42 hospitals in the 2007 survey reported that they were already designated as Baby-Friendly by the BFHI. Baby-Friendly is a common terminology that might be confused with supportive birthing practices by some respondents. Clearly more  knowledge  translation and exchange are neededabout the BFHI program and its merits so that hospitals understand and aspire to be designated as Baby-Friendly. \n\nConsiderable improvements have been   documentedrom 1993 to 2007 in policies and  practices related to breastfeeding in Canadian  hospitals. Fewer hospitals have exclusive contracts with the formula industry and provide free formula  sample packs to new  mothers. Improvement is also  seen in hospital's reported  adherence to the Ten  Steps.  "]
["Breastfeeding Supportive Services in Baby-Friendly Hospitals Positively Influenced Exclusive Breastfeeding Practice at Hospitalization Discharge and Six Months Postpartum","Int. J. Environ.Res. Public Health","Li, L. L., H. Q. Song, Y. Zhang, H. Li, M. Li, H. Jiang, Y. J. Yang, et al. “Breastfeeding Supportive Services in Baby-Friendly Hospitals Positively Influenced Exclusive Breastfeeding Practice at Hospitalization Discharge and Six Months Postpartum.” International Journal of Environmental Research and Public Health 18, no. 21 (2021). https://doi.org/10.3390/ijerph182111430.",2021,"China","Hospital","BHFI overall/all steps ","Postpartum women","This study aimed to assess the BF supportive services provided by BFHs during childbirth hospitalization, and to explore the association between in-hospital breastfeeding supportive services and EBF at the time of discharge as well as six months postpartum. The study also seeks to provide evidence on EBF at discharge and six months after delivery in order to strengthen advocacy for the BFHI and for the evaluation of hospital breastfeeding supportive services in BFHs in China.","The overall exclusive breastfeeding rate among participants was 34.4% at discharge and 52.1% at six months postpartum. Mothers who received better breastfeeding supportive services during hospital-ization were more likely to practice exclusive breastfeeding at hospitalization discharge comparedwith mothers who received poorer services (aOR: 3.00; 95% CI: 2.08, 4.35; p< 0.001). Furthermore,they were also more likely to exclusively breastfeed at six months postpartum (aOR: 1.50; 95% CI:1.03, 2.22;p= 0.033)."]
["A Geospatial Analysis of the Impact of the Baby-Friendly Hospital Initiative on Breastfeeding Initiation in North Carolina","Journal of Human Lactation","Liberty, A. L., K. Wouk, E. Chetwynd, and T. Ringel-Kulka. “A Geospatial Analysis of the Impact of the Baby-Friendly Hospital Initiative on Breastfeeding Initiation in North Carolina.” J Hum Lact 35, no. 1 (2019): 114–26. https://doi.org/10.1177/0890334418776645.",2019,"United States","Hospital","BHFI overall/all steps ","Newborns and postpartum women","This study aimed to evaluate the impact of the Baby-Friendly Hospital Initiative on breastfeeding initiation in North Carolina, with special attention to rural areas. \n\nThis study had three aims:\n\nTo estimate the association between birth at a BFH and breastfeeding initiation in North Carolina,\n\nTo estimate the association between maternal resi-dence in a North Carolina county with a BFH and breastfeeding initiation, and\n\nTo compare these affects between mothers who live in metro and nonmetro counties","Birth at a Baby-Friendly hospital was associated with increased odds of breastfeeding initiation, adjusted odds ratio = 1.7, 95% confidence interval [1.65, 1.89]. Model residuals showed significant clustering by county, with some rural areas' rates systematically overestimated. Whereas presence of a Baby-Friendly hospital in a mother's community of residence was not associated with increased initiation, birth at a Baby-Friendly hospital was associated with smaller disparities in initiation between rural and urban births.\n\nThe association between birth at a BFH and breast-feeding initiation varied nonrandomly across the state, suggestive of regional health disparities for rural versus urban counties.\n\nMaternal residence in a community with a BFH was not associated with higher odds of breastfeed-ing initiation alone or in addition to giving birth at a BFH when compared to only giving birth at a BFH.\n\nAccess to BFHs continues to be an important tool for the promotion of breastfeeding initiation in both rural and urban areas.\n\nThe BFHI is associated with higher odds of breastfeeding initiation in North Carolina. Giving birth at a BFH, particularly for rural residents, has the potential to mitigate some of the disparity observed between rural and metropolitan populations."]
["Implementation of the Baby-Friendly Hospital Initiative Steps in Iowa Hospitals","JOGNN","Lillehoj, C. J., and B. L. Dobson. “Implementation of the Baby-Friendly Hospital Initiative Steps in Iowa Hospitals.” J Obstet Gynecol Neonatal Nurs 41, no. 6 (2012): 717–27. https://doi.org/10.1111/j.1552-6909.2012.01411.x.",2012,"United States","Hospital","BHFI overall/all steps ","Hospitals","To determine the status of each of the Baby-Friendly Hospital Initiative (BFHI) Ten Steps and associated policies in Iowa hospitals","The majority of the hospitals were implementing at least three of the Ten Steps. The most widely adopted policy, encouraging breastfeeding on demand, was implemented by 83% of the hospitals. None of the hospitals had implemented all six criteria included in Step One. Step One describes a written breastfeeding policy routinely commu-nicated to all healthcare staff.\n\nImplementation of the steps varied by hospital locale; urban hospitals had higher implementation rates for Step 10 than rural hospitals.\n\nWe found that none of the Iowa hospitals com-pleting the preassessment met all of the BFHI Ten Steps. In fact, none met eight or more, and themedian number of steps attained was only three.\n\nWe found a positive association between hos-pitals that reported implementation of seven of the steps and higher breastfeeding rates at dis-charge. "]
["The Impact of Breast-Feeding on Early Neonatal   Jaundice","Clinical neonatology","Lin, Y., P. Tsao, W. Hsieh, C. Chen, and H. Chou. “The Impact of Breast-Feeding on Early Neonatal Jaundice.” Clinical Neonatology 15, no. 1 (2008): 31–35.",2008,"Taiwan","Hospital","BHFI overall/all steps ","Newborns ","The purpose of this study is to evaluate the impact of breast-feeding promotion on the incidence of hyperbilirubinemia, on peak bilirubin level and on mean days of hospitalization.","After implementation of the Baby Friendly Hospital Initiative Program, the rate of breast-feeding increased from 92.18% to 97.15% and the incidence of hyperbilirubinemia increased from 10.88% to 23.77%. In addition, the BW loss ratio, the bilirubin level on the third or fourth day, the peak bilirubin level and the mean days of hospitalization and phototherapy all increased significantly after breast-feeding promotion started (all p<0.001). The frequencies of urination and defecation on the first two days of life also decreased significantly (p<0.001). Our study also showed that infants born after the Baby Friendly Hospital Initiative Program was started to lose more BW, indicating a striking positive association between maximum BW loss ratio and rate of breast-feeding.\n\nAfter Baby Friendly Hospital Initiative Program was\nlaunched, the incidence of hyperbilirubinemia increased. This change may be due to increased weight loss caused by improper breast-feeding. Increased weight loss and breast-feeding were associated with the increase in the incidence of hyperbilirubinemia, the bilirubin level on the third or fourth day as well as the mean days of hospitalization and phototherapy. Although breast-feeding remains the single best choice for infants and parents, jaundice and prolonged hospitalization related to improper breast-feeding should be kept in mind by medical personnel."]
["Maternal Country of Birth and Exclusive Breastfeeding During the First In-Hospital Day in Portugal: The Influence of the Baby-Friendly Hospital Initiative","Journal of Human Lactation","Lisi, C., C. de Freitas, and H. Barros. “Maternal Country of Birth and Exclusive Breastfeeding during the First In-Hospital Day in Portugal: The Influence of the Baby-Friendly Hospital Initiative.” Journal of Human Lactation 37, no. 1 (2021): 147–57. https://doi.org/10.1177/0890334420982248.",2021,"Portugal","Hospital","BHFI overall/all steps ","Postpartum women","To determine (1) if association between maternal country of birth and first day in-hospital exclusive breastfeeding exists in Portugal and (2) if any association is affected by giving birth in a Baby-Friendly Hospital","First day in-hospital exclusive breastfeeding rates were high among both migrant and native participants (89.2% vs. 87.4%). Migrants were more likely to exclusively breastfeed when compared to natives (OR = 1.19, 95% CI [1.00, 1.41]). In non-Baby-Friendly Hospitals, a positive association was found between participants from Eastern European countries (aOR = 2.46, 95% CI [1.27, 4.78]) and first day in-hospital exclusive breastfeeding. In accredited hospitals, maternal country of birth did not influence exclusive breast-feeding during the first 24 hr."]
["Jaana Lojandera, AnnaAxelina, Paula Bergman, Hannakaisa Niela-VilÃ©n","Midwifery","Lojander, J., A. Axelin, P. Bergman, and H. Niela-Vilen. “Maternal Perceptions of Breastfeeding Support in a Birth Hospital before and after Designation to the Baby-Friendly Hospital Initiative: A Quasi-Experimental Study.” Midwifery 110 (2022). https://doi.org/10.1016/j.midw.2022.103350.",2022,"Finland","Hospital","BHFI overall/all steps ","Postpartum women","The purpose of this study was to examine maternal perceptions of postnatal breastfeeding\nsupport in the hospital before and after designation to the Baby-Friendly Hospital Initiative (BFHI). Further maternal and infant characteristics associated with the maternal perception of breastfeeding support\nwere investigated. ","Mothers in the post-test group (median 6.1, IQR 5.4-6.4) perceived breastfeeding support more\nadherent to the standards the BFHI compared with mothers in the pre-test group (median 5.0, IQR 4.2-\n5.8) (p < 0.001). Fifteen of 20 of the measured breastfeeding support practices improved after the hospital's designation to the BFHI. The largest difference between groups was observed for multipara mothers\n(median 4.6 vs 6.0, p < 0.001), older mothers (> 35 years) (median 4.4 vs 5.8, p < 0.001), and mothers\nwith a longer history of breastfeeding (6-12 months) (median 4.4 vs 6.2, p < 0.001). Before the BFHI\ndesignation, multipara mothers and mothers who gave birth to an infant with low Apgar scores (< 7)\nperceived breastfeeding support less adherent to the BFHI standards than did primiparas or mothers of\nan infant with high Apgar scores (< 7). After the BFHI designation, mothers who experienced preterm\nbirth (GA < 37 weeks) perceived breastfeeding support less adherent to the BFHI standards compared\nwith mothers who experienced a full-term birth."]
[" Exposure to baby-friendly hospital practices and mothersâ€™ achievement of their planned duration of breastfeeding","BMC Pregnancy and Childbirth","Lok, K. Y. W., C. L. Y. Chow, H. S. L. Fan, V. H. S. Chan, and M. Tarrant. “Exposure to Baby-Friendly Hospital Practices and Mothers’ Achievement of Their Planned Duration of Breastfeeding.” BMC Pregnancy Childbirth 20, no. 1 (2020): 261. https://doi.org/10.1186/s12884-020-02904-0.",2020,"Hong Kong","Hospital","BHFI overall/all steps ","Newborns and postpartum women","This study aims to examine the effect of exposure to baby-friendly hospital practices on mothers' achievement of their planned duration of breastfeeding","Among baby-friendly hospital practices, feeding only breast milk during the hospitalization and providing information about breastfeeding support on discharge were associated with participants' achieving their individual breastfeeding intentions. After adjustment, when compared with women who experienced one baby-friendly practice, participants who experienced six baby-friendly hospital practices were significantly more likely to achieve their planned duration of breastfeeding.\n\nStep 6, giving newborns only breast milk almost doubled a mother's likelihood of achieving her planned duration of breatsfeeding. \n\nOverall, each of the baby-friendly steps is highly inter-connected with the others, structurally and physiologically, and the steps are statistically correlated with each other. Although only two of the six measured baby-friendly practices were individually associated with participants achieving their planned duration of breastfeeding,  there  was  a  clear  dose-response  pattern  and exposure to increasing numbers of baby-friendly practices was associated with increasingly higher odds of participants reaching their individual goals. "]
["Scoping Review of Baby-FriendlyHospital Initiative Compliance andBreastfeeding Initiation in Sri Lanka","JOGNN","Lokeesan, L., E. Martin, and Y. Miller. “Scoping Review of Baby-Friendly Hospital Initiative Compliance and Breastfeeding Initiation in Sri Lanka.” J Obstet Gynecol Neonatal Nurs 51, no. 2 (2022): 153–65. https://doi.org/10.1016/j.jogn.2021.12.005.",2022,"Sri Lanka","Hospital","BHFI overall/all steps ","Academic study","To synthesize the evidence for associations between Baby-Friendly Hospital Initiative (BFHI) complianceand breastfeeding initiation in Sri Lanka","We synthesized the data narratively to address the research questions. We identified contradictingreports of the prevalence of breastfeeding initiation (23.5%-100%) across Sri Lankan hospitals. Breastfeeding initi-ation was significantly associated with mode of birth. We identified inconsistent compliance with the BFHI, and poorcompliance was associated with inadequate staff training and ineffective monitoring systems."]
["The DC Breastfeeding-Friendly Hospital Initiative: An Evaluation of Hospitalsâ€™ Support for Breastfeeding in the Capital of the United States","Journal of Human Lactation","Long, S. A., M. A. Young, J. A. Tender, V. P. Dewitty, K. Logan, M. Kadeshe, C. Ryan, and S. G. Haynes. “The DC Breastfeeding-Friendly Hospital Initiative: An Evaluation of Hospitals’ Support for Breastfeeding in the Capital of the United States.” J Hum Lact 29, no. 4 (2013): 465–68. https://doi.org/10.1177/0890334413478834.",2013,"United States","Hospital","Becoming/pre BFHI","Health facility level","Prior to the DC Breastfeeding-Friendly Hospital Initiative, no maternity facilities in Washington, DC, were recognized as Baby-Friendly. The purpose of this project was to help facilities identify areas to focus on in pursuit of this goal.","Most facilities were receptive to the intervention, resulting in modest improvements in all areas reviewed. \n\nAfter the intervention, modest improvements were noted in the mention of breastfeeding services on the facility websites. The 2 facilities that completed breastfeeding policy revisions improved their scores. Five facilities completed the postintervention practices review. The greatest practice improvements occurred in the following areas: (1) increased skin-to-skin/breastfeeding initiation after surgical deliveries, (2) reduced distribution of formula company sponsored discharge bags, and (3) increased rooming in\n\nThe DCBFHI confirmed that disparities exist in birthing facilities throughout DC with regard to their breastfeeding support. "]
["Baby-Friendly Hospital Initiative: evaluation of the Ten Steps to Successful Breastfeeding","Rev Paul Pediatr","Lopes Sda, S., M. R. Laignier, C. C. Primo, and F. M. Leite. “Baby-Friendly Hospital Initiative: Evaluation of the Ten Steps to Successful Breastfeeding.” Rev Paul Pediatr 31, no. 4 (2013): 488–93. https://doi.org/10.1590/s0103-05822013000400011.",2013,"Brazil","Hospital","BHFI overall/all steps ","Health workers and postpartum women and others","To asses the performance of the Ten Steps to Suc-cessful Breastfeeding in an university hospital.","Although the hospital does not have a policy that addresses promotion, protection and support for breastfeeding, 93.3% of the mothers had contact with their babies immediately after birth (step 4), 83.3% of the professionals guided mothers how to breastfeed (step 5), 86.6% of the neonates did not receive any food or drink other than breast milk (step 6), 100% of babies were housed together with their mothers (step 7), 83.3% of the women were encouraged for breastfeeding on demand (step 8) and 100% of the infants did not use bottles or pacifiers (step 9).\n\n60% of the steps were completed by the hospital.\n\nStep1:The maternity service does not have a breastfeeding policy that addresses the Ten Steps to Successful Breastfeeding.\t \n\nStep 2:TheInstitution does not have written documents with the content of training courses for breastfeeding promotion and support, confirming what 64.4% of staff members informed regarding the lack of breastfeeding training and of baby-friendly practices. 86.6% of staff members properly answered to at least four questions about breastfeeding support and promotion. 33.3% of respondents correctly mentioned at least two topics that should be discussed with a pregnant woman if she expressed the intention of offering something other than breast milk.\t \n\nStep 3: The nurse responsible for the ante-natal care pointed out that pregnant women are not informed about the importance and the management of breastfeeding during visits; in addition, there were no records of this topic on medical charts.  Professionals do not consider woman's intention to breastfeed when deciding about the use of sedatives and analgesics during delivery, although being aware of the effects of these drugs on breastfeeding. Future mothers are not protected from commercial promotion, whether oral or written, and emphasizes that no group meetings are held with pregnant women to deal with any topic. Confirming this information, 100% of respondents said they did not receive guidance on bottle feeding. Moreover, 90% of the pregnant women who had access to prenatal care were not able to describe the risks of offering complementary food along with breast milk during the first six months of infant's life, which confirms the information provided by the nurse. It was also found that, in 90% of the interviews, pregnant women were not able to describe the importance of early skin-to-skin contact with their children and the value of rooming-in.\t\n\nStep 4: According to the BFHI, this step is interpreted as: putting babies in direct contact with their mothers immediately after birth for at least one hour and en-courage mothers to identify if their baby is ready to be breastfed, offering help if needed.\u009d Of the 29 randomly selected mothers who underwent vaginal and cesarean section without general anesthesia, 93.3% said that their babies were handed to them immediately or up to five minutes after delivery. \n\nStep5: As for instructing recently delivered mothers about the breastfeeding process, 73.3% of the members of the clinical staff reported that they provided guidance on proper positioning and latch-on of the breast. However, 66.6% of the mothers properly demonstrated this process. Of the 30 professionals of the clinical staff, 83.3% said that they taught mothers how to express milk manually, properly demon-strating the technique. Nevertheless, only 40% of recently delivered mothers said that someone of the staff offered to teach them how to extract milk manually. As for assistance in breastfeeding, 60% of mothers in the postpartum period said that the staff provided support with breastfeeding on the second time when the baby was fed or in the six hours following delivery. \n\nStep 7: In post partum wards, 100% of the babies were housed together with their mothers, not taking into account mothers whose babies were admitted to the NICU. \n\nStep 8: When the 30 recently delivered mothers were asked about newborn's feeding, 20% of them reported that they received guidance on how to recognize baby's signs of hunger. However, none of them were able to mention at least two of these signs and 83.3% were stimulated to feed their children whenever and for how long the babies wanted.\n\nStep 9: All babies observed in postpartum rooms/ wards did not use bottles and pacifiers, corroborating the report of 100% of the interviewed mothers.\n\nStep 10: The questions of this step aimed to identify if the hospital referred mothers to breastfeeding support groups on discharge. Thus, 66.6% of the recently delivered mothers were informed about where to receive support to breastfeed their babies after discharge and correctly mentioned a source of support."]
["Compliance with the â€œBabyâ€\u0090friendly Hospital Initiative for Neonatal Wardsâ€\u009d in 36 countries","Maternal and Child Nutrition","Lubbe, Welma, Deena Yael Meerkin, Leslie Wolff, Kiyoshi Hatasaki, Mona A. Alsumaie, Socorro De Leon‐Mendoza, Yvonne P. M. Ng, et al. “Compliance with the ‘Baby‐friendly Hospital Initiative for Neonatal Wards’ in 36 Countries.” Maternal & Child Nutrition 15, no. 2 (2019): N.PAG-N.PAG. https://doi.org/10.1111/mcn.12690.",2019,"36 countries","Hospital","BFHI in Neonatal Intensive Care Unit (NICU)","NICU neonatal wards","This crossâ€\u0090sectional survey aimed to measure compliance on a global level withthe Neo-BFHI's expanded Ten Steps to successful breastfeeding and three Guiding Principles in neonatal wards","An international Neo-BFHI compliance score of 77 out of 100 and country scores higher than 50 for all 36 participating countries demonstrate that neonatal wards around the world are working to support breastfeeding.\n\nThe median international overall score was 77, and median country overall scores ranged from 52 to 91. GuidingPrinciple 1 (respect for mothers), Step 5 (breastfeeding initiation and support), and Step 6 (human milk use) had the highest scores, 100, 88, and 88, respectively. \n\nStep 3 (antenatal information) and Step 7 (rooming-in) had the lowest scores, 63 and 67, respectively. \nHigh-\u0090income countries had significantly higher scores for Guiding Principles 2 (family-centered care), Step 4 (skin to skin contact), and Step 5. Neonatal wards in hospitals ever-designated Baby-friendly had significantly higher scores thanthose never designated. \n\nSixty percent of managers stated they would like to obtain Neo-BFHI designation. Currently, Neo-BFHI recommendations are partly implementedin many countries. The high number of participating wards indicates international readiness to expand Baby-friendly standards to neonatal settings. "]
["Nurses' Perspectives on the Process of Attaining Baby-Friendly Designation","Nurs Women's Health","Lundeen, S., S. Sorensen, M. Bland, S. George, and B. Snyder. “Nurses’ Perspectives on the Process of Attaining Baby-Friendly Designation.” Nurs Womens Health 20, no. 3 (2016): 277–87. https://doi.org/10.1016/j.nwh.2016.03.004.",2016,"United States","Hospital","BHFI overall/all steps ","Health workers","This study explores and describes the process of attaining Baby-Friendly designation from nurses' perspectives.","The following themes were revealed: Resistance, Culture, Investment in the Journey, Teamwork, and Source of Pride. Results indicate that comfortable yet antiquated practices led to fear of change and resistance. Initial culture shock was mediated by a successful education model, powerful experiences, and positive outcomes."]
["A Controlled Study on Baby-Friendly Communities in Italy: Methods and Baseline Data","BREASTFEEDING MEDICINE","Macaluso, A., M. E. Bettinelli, E. M. Chapin, L. Córdova do Espírito Santo, R. Mascheroni, A. M. Murante, M. Montico, and A. Cattaneo. “A Controlled Study on Baby-Friendly Communities in Italy: Methods and Baseline Data.” Breastfeed Med 8, no. 2 (2013): 198–204. https://doi.org/10.1089/bfm.2012.0130.",2013,"Italy","Community ","BFCI only  ","Newborns and postpartum women","This study reports the research methods and baseline data of a project aimed at assessing the effect of anintervention based on the 7 Steps of the Baby Friendly Community Initiative (BFCI) on the rate of exclusive breastfeeding at 6 months in Italy","At baseline, there were no significant differences in breastfeeding rates at birth (n=1,781) and at 3(n=1,854), 6 (n=1,601), and 12 (n=1,510; loss to follow-up, 15.2%) months between groups. At birth, 96% of mothers initiated breastfeeding, 72% exclusively (recall from birth). At 3 months, 77% of infants were breastfed, 54% exclusively with 24-hour and 46% with 7-day recall. At 6 months, the rate of any breastfeeding was 62%, with 10% and 7% exclusive breastfeeding with 24-hour and 7-day recall, respectively. At 12 months, 31% of the children continued to breastfeed.\n\nIt is too early to report about the degree of implementation of the 7 Steps of the BFCI in the 18 LHAs, let alone speculate on the effectiveness of the initiative. "]
["Maternal knowledge in complementary feeding following Baby Friendly Community Initiative in Koibatek, Kenya","Maternal and Child Nutrition","Maingi, M., J. Kimiywe, and S. Iron-Segev.  “Maternal Knowledge in Complementary Feeding Following Baby Friendly Community Initiative in Koibatek, Kenya.” Matern Child Nutr 16, no. 4 (2020): e13027. https://doi.org/10.1111/mcn.13027.",2020,"Kenya","Community ","BFCI only  ","Newborns and postpartum women","This study assessed maternal knowledge of attributes of complementary feeding following implementation of BFCI in Koibatek, Kenya. ","Overall, the study found that most (98%) mothers were knowledgeable regarding the age of introduction of solid food to an infant. On the question of introducing food to an infant, allmothers in the intervention group knew that in addition tobreastfeeding, food should be introduced at 6 months. On durationof breastfeeding, a higher number of mothers in the interventiongroup (91%) stated that breastfeeding should continue up to atleast 2 years compared with the 71% mothers in the control group. \n\nThe study found that a significantly greater number of mothers in the intervention group were more knowledgeable about proper breastfeeding and complementary feeding aspects compared with controls. About half (53%) of mothers in the intervention group had high knowledge scores in comparison with 20% of mothers in the control group. When the relationship between mothers' knowledge and complementary feeding practices (minimum meal frequency, minimum dietary diversity and minimum acceptable diet) was assessed, significant associations were observed. The odds of having a high knowledge score regarding complementary feeding practices were significantly higher for the intervention group compared with the control group. The BFCI intervention effectively improved mothers' knowledge on complementary feeding and correlated with improved feeding practices. "]
["Effectiveness of Baby Friendly CommunityInitiative (BFCI) on complementary feeding in Koibatek, Kenya: a randomized controlstudy","BMC Public Health","Maingi, M., J. Kimiywe, and S. Iron-Segev. “Effectiveness of Baby Friendly Community Initiative (BFCI) on Complementary Feeding in Koibatek, Kenya: A Randomized Control Study.” BMC Public Health 18, no. 1 (2018): 600. https://doi.org/10.1186/s12889-018-5519-1.",2018,"Kenya","Community ","BFCI only  ","Newborns ","This study aimed at assessing the effectiveness of BFCI on complementary feeding practices of children aged 6-23 months, by comparing intervention and control groups.","The findings of this study demonstrate that the BabyFriendly Community Initiative had a positive impact oncomplementary feeding practices. Mothers in the intervention groups had significantly better frequency offeeding, dietary diversity and minimum acceptable dietcompared to control groups. These results remained significant even after adjusting for socio-demographic factors; the age of mother, marital status, education level, religion and the main source of income. \n\nA statistically significantly higher proportion of children in the intervention group compared to the controlgroup attained minimum dietary diversity, minimum meal frequency and minimum acceptable diet. The odds of attaining minimum dietary diversity, minimum meal frequency and minimum acceptable diet were statistically significantly higher for the intervention group compared to control group.\n\nIn this study, there were more Muslim mothers in the control group compared to the intervention group. It was put into consideration that mothers in control group could have better breastfeeding practices when compared to those in intervention group, since Muslim religion directs that mothers breastfeed their children.However, this study found that complementary feeding practices are better in the intervention group compared to the control group. It is possible that Islam instructs breastfeeding but may not be clear on appropriate complementary feeding."]
["Healthcare Professionalsâ€™ Breastfeeding Attitudes and Hospital Practices During Delivery and in Neonatal Intensive Care Units: Pre and Post Implementing the Baby-Friendly Hospital Initiative","Journal of Human Lactation","Mäkelä, H., A. Axelin, T. Kolari, T. Kuivalainen, and H. Niela-Vilén. “Healthcare Professionals’ Breastfeeding Attitudes and Hospital Practices During Delivery and in Neonatal Intensive Care Units: Pre and Post Implementing the Baby-Friendly Hospital Initiative.” J Hum Lact 38, no. 3 (2022): 537–47. https://doi.org/10.1177/08903344211058373.",2022,"Finland","Hospital","BHFI overall/all steps ","Health workers","To determine healthcare professionals' breastfeeding attitudes and hospital practices before and after the implementation of the Baby-Friendly Hospital Initiative.","The healthcare professionals' breastfeeding attitude scores increased significantly after the implementation of the Baby-Friendly Hospital Initiative, difference = 0.16, (95% CI [0.13, 0.19]) and became breastfeeding favorable among all professional groups in each study unit. Positive changes in breastfeeding-supportive hospital practices were achieved. The infants had significantly more frequent immediate and uninterrupted skin-to-skin contact with their mothers. The rate of early breastfeeding, as well as the number of exclusively breastfed infants, increased. Breastfeeding attitudes became more facilitating and less disempowering across professional groups among HCPs who participated in both data collection points. "]
["Breastfeeding policies and practices in health care facilities in the Western Cape Province, South Africa","South African Journal of Clinicial Nutrition","Marais, D., E. H. Koornhof, L. M. du Plessis, C. E. Naude, K. Smit, R. Treurnicht, E. Hertzog, M. Alexander, I. Kosaber, and L. Cruywagen. “Breastfeeding Policies and Practices in Healthcare Facilities in the Western Cape Province, South Africa.” SAJCN - South African Journal of Clinical Nutrition 23, no. 1 (2010): 40–45.",2010,"South Africa","Hospital","BHFI overall/all steps ","Health workers and postpartum women","An initial study was therefore conducted to assess the extent of the implementation of the Ten Steps in both public and private maternity facilities. \n\nPoor performance for some steps led to a follow-up study to investigate the knowledge and attitudes of health care workers (HCWs) and mothers alike and to  evaluate the exclusive BF (EBF) practices  of  mothers  attending private BF clinics.","During the initial study, lower mean scores were noted for Steps 1, 2, 6 and 10. The overall implementation of the Ten Steps was average. The findings highlighted the importance of the establishment and implementation of BF policies, of appropriate and continuous BF training and better referral systems to ensure initiation and establishment of early BF, EBF practices and support on an ongoing basis to ensure the best start in life for infants."]
["Breastfeeding with and without the WHO/UNICEF baby-friendly hospital initiative","Medicine","Marinelli, A., V. Del Prete, E. Finale, A. Guala, C. P. Pelullo, and F. Attena. “Breastfeeding with and without the WHO/UNICEF Baby-Friendly Hospital Initiative: A Cross-Sectional Survey.” Medicine (Baltimore) 98, no. 44 (2019): e17737. https://doi.org/10.1097/md.0000000000017737.",2019,"Italy","Hospital","BHFI overall/all steps ","Postpartum women","n this study, we compared breastfeeding-related information received,knowledge and behaviours among postpartum women in Baby-Friendly Hospital Initiative accredited and non-accredited hospitals.","Compared with Piedmont, in Campania hospitals there was a rate of breastfeeding of 44.3% vs 89.3%, a skin-to-skin contact between mother and child of 74.5% vs 90.7% and first milk feed within 2hours of 15.0% vs 87.2%. The Campania group hadfewer problems with child latching. The Campania group reported receiving less information about breastfeeding in generalcompared with the Piedmont group. In general, both groups showed good basic knowledge about different aspects of breastfeeding. In both regions, about 90% reported that the information received during the antenatal classes simplified the breastfeeding experience. "]
["Does Breastfeeding Education Affect Nursing Staff Beliefs, Exclusive Breastfeeding Rates, and Baby-Friendly Hospital Initiative Compliance?The Experience of a Small, Rural Canadian Hospital","Journal of Human Lactation","Martens, P. J. “Does Breastfeeding Education Affect Nursing Staff Beliefs, Exclusive Breastfeeding Rates, and Baby-Friendly Hospital Initiative Compliance? The Experience of a Small, Rural Canadian Hospital.” J Hum Lact 16, no. 4 (2000): 309–18. https://doi.org/10.1177/089033440001600407.",1993,"Canada","Hospital","BHFI overall/all steps ","Health workers and postpartum women and their babies ","The effectiveness of a breastfeeding education intervention consisting of a 1½-hour mandated session for all nursing staff, with an optional self-paced tutorial, was evaluated in a small rural Canadian hospital. ","Over a 7-month period, the intervention hospital experienced an increase in BFHI compliance (24.4 vs. 31.9, P<.01), breastfeeding beliefs(55.0 vs. 58.8,P<.05), and exclusive breastfeeding rates (31% vs. 54% of breastfed babies, P<.05) but no change in breastfeeding attitudes (44.0 vs. 44.9, P=.80). The control site experienced no change in BFHI compliance, beliefs, or attitudes but a significant decrease in exclusive breastfeeding rates (43% vs. 0%, P<.05)"]
["How Baby-friendly are Manitoba Hospitals? The Provincial Infant Feeding Study","CANADIAN JOURNAL OF PUBLIC HEALTH","Martens, P. J., S. J. Phillips, M. S. Cheang, and V. Rosolowich. “How Baby-Friendly Are Manitoba Hospitals? The Provincial Infant Feeding Study. Breastfeeding Promotion Steering Committee of Manitoba.” Can J Public Health 91, no. 1 (2000): 51–57. https://doi.org/10.1007/bf03404254.",1993,"Canada","Hospital","BHFI overall/all steps ","Postpartum women","To examine: correlations between breast-feeding policies and actual practices in Manitoba hospitals; compliance with Baby-Friendly Hospital Initiative (BFHI) criteria; and associations between hospital practices and two-week breastfeeding duration","The results highlighted the need for policy and practice changes to comply with BFHI criteria. 92% initiated breastfeeding, and 84% were breastfeeding at two weeks postpartum. Independent predictors of weaning included: in-hospital supplementation (adjusted RR=2.1, 95% CI 1.02-4.36, p=0.04); temporarily interrupting breast-feeding while in hospital (adjusted RR = 4.9,95% CI 2.7-8.9, p=0.0001); no previous breast-feeding experience (adjusted RR = 2.5, 95% CI1.4-4.4, p=0.002); and Grade 12 or less maternal education (adjusted RR = 2.0, 95% CI 1.2-3.5, p=0.01)."]
["The New Zealand/Aotearoa Baby-Friendly Hospital Initiative Implementation Journey:Piki Ake Te Tihiâ€”â€œStrive for Excellenceâ€\u009d","Journal of Human Lactation","Martis, R., and J. Stufkens. “The New Zealand/Aotearoa Baby-Friendly Hospital Initiative Implementation Journey: Piki Ake Te Tihi--\"strive for Excellence\".” J Hum Lact 29, no. 2 (2013): 140–46. https://doi.org/10.1177/0890334413480849.",2013,"New Zealand","Hospital","BHFI overall/all steps ","Health facility level","Describes the implementation journey of New Zealand/Aotearoa Baby-Friendly Hospital Initiative (aim of paper not stated clearly)","Successful BFHI implementation was achieved through a number of factors, including the establishment of a national body (NZBA) with oversight of BFHI facility implementation and auditing, Ma Ì„ori and consumer participation at all levels, the recertification requirements for midwives of breastfeeding education by the Midwifery Council, and maternity facilities having paid BFHI coordinators. Once the NZBA was established, BFHI accreditation of maternity facilities had a rapid rise from 0% in 2000 to 96.1% in 2011 (74 of 77 facilities). Data collected over this period shows a 28.8-percentage-point increase of exclusive breastfeeding at discharge from maternity facilitates between 2001 (55.6%) and 2011 (84.4%)."]
["IMPROVING THE NUMBER OF MOTHERS BREASTFEEDING IN THE POSTPARTUM PERIOD","Primary Care Update for Ob/Gyns","McCreath, W. A., S. Wilcox, V. Laing, D. Crump, and J. Gilles. “Improving the Number of Mothers Breastfeeding in the Postpartum Period.” Primary Care Update for Ob/Gyns 8, no. 1 (2001): 40–43. https://doi.org/10.1016/S1068-607X(00)00069-X.",2001,"United States","Hospital","BHFI overall/all steps ","Postpartum women","The objective of this study was to review an experience at Jackson Memorial Hospital, Miami, Florida that has resulted in an increase in the percentage of mothers breastfeeding at postpartum discharge. Data was obtained from postpartum interviews in 1993, which provided the percentage of mothers breastfeeding at discharge.  These early efforts led to the implementation of a Baby-Friendly initiative and intent in 1996 and the formation of a mother-baby unit in 1997.","Ten percent of mothers were breastfeeding  at  postpartum discharge. After implementing a pro-gram in 1994, 41% were breast-feeding at discharge. There was a decline in the number of mothers breastfeeding during the postpartum period from  discharge. At 3 days postpartum, 80% of patients were  breastfeeding  followed  by 64%, 37%, and 17% at 2 weeks, 6 weeks, and 3 months from  discharge, respectively. The percentage of mothers opting not to breastfeed at 3 days after discharge was 20%, followed by 12% from 3 days to 2 weeks  post discharge, by 21% 2 weeks to 6 weeks post discharge, and finally by 16% from 6 weeks to 3 months post discharge. In 1998, 70% of  patients were breastfeeding, and in 1999,71% of patients were breastfeeding upon postpartum  discharge.\n\nThe data show that by implementing  programs  to  promote breast-feeding, through education, encouragement, and reinforcement, one can increase  the  number of mothers who breastfeed at post-partum discharge. However, there is an inverse relationship betweenthe duration of the postdischarge period and the number of mothers breastfeeding. "]
["The Baby-Friendly Hospital Initiative Increases Breastfeeding Rates in a US Neonatal Intensive Care Unit","Journal of Human Lactation","Merewood, A., B. L. Philipp, N. Chawla, and S. Cimo. “The Baby-Friendly Hospital Initiative Increases Breastfeeding Rates in a US Neonatal Intensive Care Unit.” J Hum Lact 19, no. 2 (2003): 166–71. https://doi.org/10.1177/0890334403252475.",2003,"United States","Hospital","BHFI overall/all steps ","Newborns ","This study evaluated the impact of a Baby-Friendly designation on breastfeeding rates in a US neonatal intensive care unit (NICU). The medical records of all surviving infants directly ad-mitted to the Boston Medical Center's level III, 15-bed NICU in 1995 (before Baby-Friendlypolicies were implemented) and 1999 (when Baby-Friendly status was granted) were re-viewed.","The NICU breastfeeding initiation rate increased from 34.6%(1995) to 74.4% (1999) (P< .001). Among 2-week-old infants, the proportion receiving anybreast milk rose from 27.9% (1995) to 65.9% (1999) (P< .001), and the proportion receiving breast milk exclusively rose from 9.3% (1995) to 39% (1999) (P= .002). The implementation of Baby-Friendly policies leading to a Baby-Friendly designation was associated with increased breastfeeding initiation and duration rates.\n\nIn  both healthy term and NICU infants, the full  implementation of Baby-Friendly policies at the BMC was associated with a significant rise in  breastfeeding  rates. These increases occurred despite the high percentage of women from under privileged backgrounds and racial minorities, the groups traditionally most difficult to influence in termsof breastfeeding initiation and duration.As practicing clinicians, we believe that many corre-lates associated with low breastfeeding rates in these populations (such as poverty, a lack of access to healthcare, and suboptimal educational status)  are  compounded by the NICU setting. A lack of education on the benefits of breast milk for premature infants, a lack of medical insurance for breast pumps, and the over-whelming practical issues of maintaining contact withhospitalized infants present extra barriers to breastfeed-ing  NICU  infants  for  impoverished  families  and  putthem in double jeopardy. Thus, the importance of a hos-pital  system  that  is  designed  (by  following  the  TenSteps) to support  breastfeeding  and  ease  the  complicated NICU situation is critical in  vulnerable, low-income women who may lack the  resources and the ability to advocate for themselves and for their infants.\n\nDuring the process of becoming Baby-Friendly, however, it was discovered that in many cases,  a mother's ability to maintain lactation (as specified bystep 5) while separated from her infant was compro-mised because of the lack of an electric breast pump athome. This was due primarily to inadequate or nonexis-tent health insurance and to the inaccessibility of breastpumps theoretically covered by insurance (the process of obtaining  a  pump proved too complicated for thefamily). In addition, the large percentage of impover-ished  women at the BMC meant that many  motherscould not afford to rent breast pumps privately. In anattempt to remedy this situation and follow step 5, staff members were trained in assisting  mothers  to  obtainpumps via insurance, and a grant-funded program wasinitiated in 1998 to ensure that pumps were available athome to all women who needed them, regardless of their financial situations. "]
["Breastfeeding Duration Rates and FactorsAffecting Continued Breastfeeding Among Infants Born at an Inner-City US Baby-Friendly Hospital","Journal of Human Nutrition","Merewood, A., B. Patel, K. N. Newton, L. P. MacAuley, L. B. Chamberlain, P. Francisco, and S. D. Mehta. “Breastfeeding Duration Rates and Factors Affecting Continued Breastfeeding among Infants Born at an Inner-City US Baby-Friendly Hospital.” J Hum Lact 23, no. 2 (2007): 157–64. https://doi.org/10.1177/0890334407300573.",2008,"United States","Hospital","BHFI overall/all steps ","Newborns ","The objectives of this study were to obtain breastfeeding rates at 6 months among babies born in a US Baby-Friendly hospital and to assess factors associated with continued breastfeeding at 6 months. ","Of 336 eligible infants, 248(74%) attended the 6-month well-child visit and 37.1% (92/248) were breastfeeding at 6 months. In multivariate logistic regression, the likelihood of breastfeeding at 6 months was decreased by presence of a feeding problem in the hospital (AOR 0.27; 95% CI 0.07-0.99), whereas the likelihood of breastfeeding at 6 months increased with maternal age (AOR 1.05;95% CI 1.00-1.10) and for mothers born in Africa (AOR 4.29; 95% CI 1.36-13.5) or of unrecorded birthplace (AOR 3.29; 95% CI 1.38-7.85). Breastfeeding duration is traditionally poor in low-income, black populations in the United States. Among a predominantly low-income and black population giving birth at a US Baby-Friendly hospital, breastfeeding rates at 6 months were comparable to the overall US population.\n\nBMC has a high number of non-US-born women."]
["Breastfeeding Rates in US Baby-Friendly Hospitals: Results of a National Survey","Paediatrics","Merewood, A., S. D. Mehta, L. B. Chamberlain, B. L. Philipp, and H. Bauchner. “Breastfeeding Rates in US Baby-Friendly Hospitals: Results of a National Survey.” Pediatrics 116, no. 3 (2005): 628–34. https://doi.org/10.1542/peds.2004-1636.",2005,"United States","Hospital","BHFI overall/all steps ","Postpartum women","The objectives of this study were to analyze all available breastfeeding data from US Baby-Friendly hospitals in 2001 to determine whether breastfeeding rates at Baby-Friendly designated hospitals differed from average US national, regional, and state rates in the same year and to determine prime barriers to implementation of the Baby-Friendly Hospital Initiative.","The mean breast-feeding initiation rate for the 28 Baby-Friendly hospitalsin 2001 was 83.8%, compared with a US breastfeeding initiation rate of 69.5% in 2001. The mean rate of exclusive breastfeeding during the hospital stay (16 of 29 hospitals) was 78.4%, compared with a national mean of 46.3%. \n\nIn simple linear regression analysis, breastfeeding rates were not associated with number of births per institution or with the proportion of black or low-income patients. Of the Ten Steps to Successful Breastfeedingthe 3 described as most difficult to meet were Steps 6, 2,and 7. The reason cited for the problem with meeting Step 6 was the requirement that the hospital pay for infant formula."]
["Addressing Racial Inequities in Breastfeeding in the Southern United States","Pediatrics","Merewood, Anne, Kimarie Bugg, D. Laura Burnham, Kirsten Krane, Nathan Nickel, Sarah Broom, Roger Edwards, and Lori Feldman-Winter. “Addressing Racial Inequities in Breastfeeding in the Southern United States.” Pediatrics 143, no. 2 (2019): 1–10. https://doi.org/10.1542/peds.2018-1897.",2019,"United States","Hospital & Community","Becoming/pre BFHI","Postpartum women","Our goal was to determine if a hospital- and community-based initiative in the Southern United States could increase compliance with the Ten Steps, lead to Baby-Friendly designation, anddecrease racial disparities in breastfeeding.","The disparity in breastfeeding initiation between African American and white infants decreased by 9.6 percentage points over the course of 31 months. Breastfeeding initiation increased from 66% to 75% for all races combined, and exclusivity increased from 34% to 39%. Initiation and exclusive breastfeeding among African American infants increased from 46% to 63%  and from 19% to 31%  respectively. Skin-to-skin care after cesarean delivery was significantly associated with increased breastfeeding initiation and exclusivity in all races; rooming in was significantly associated with increased exclusive breastfeeding in African American infants only.\n\nOnly 1 hospital gained Baby-Friendly designation within the project time frame, we might have expected more hospitals to actually gain designation. However, we conclude that the Baby-Friendly process takes time to implement safely and that full compliance fora multiple-hospital initiative within a 3-year time frame may not be realistic, especially in regions where practices require the most change.\n\nDuring the process, many out dated and non-evidence-based practices, such as breast binding, universal trials of swallowing with bottles of sterile water, physician orders stating that infants must be fed every 2 to 3 hours, nasogastric tubal insertion for healthy newborns, long periods of maternal/infant separation, and supplementation of all newborns with glucose water to \"prevent hypoglycemia\" came to light. Evidence-based practices, such as delayed cord clamping, placing infants on their backs for safe sleep, and visits to the pediatrician within the American Academy of Pediatrics recommended 48 hours post discharge time frame, were often lacking. As hospitals worked toward improving practices, policies and practices were adapted to eliminate these unsafe practices and replace them with updated, evidence-based care. \n\nAs a result of this success, the project has been refunded by The Kellogg Foundation and by the Bower Foundation for 3 more years in Mississippi, with a goal of Baby-Friendly designation for all Mississippi birthing hospitals. In late 2018, CHAMPS received a new grant from the Bower Foundation to assist with sustainability, which will also be maintained through Baby-Friendly USA's ongoing reassessment requirements for retaining Baby-Friendly designation."]
["Exclusive Breastfeeding Rates and Associated Factors in Swiss Baby-Friendly Hospitals","Journal of Human Lactation","Merten, S., and U. Ackermann-Liebrich. “Exclusive Breastfeeding Rates and Associated Factors in Swiss Baby-Friendly Hospitals.” J Hum Lact 20, no. 1 (2004): 9–17. https://doi.org/10.1177/0890334403261017.",2004,"Switzerland","Hospital","BHFI overall/all steps ","Newborns ","Monitoring of infant feeding and related health care practices was introduced in all 28 Swiss Baby-Friendly Hospitals to assess exclusive breastfeeding rates and potentially associated factors. Analysis of the monitoring data  wasexpected to address the following goals:\n\n1.  To investigate the prevalence of exclusive breast-feeding at the beginning of the monitoring in allSwiss Baby-Friendly hospitals, which were certified in different years. Additionally, related health care practices needed to be investigated.We suspected differences between health facilities  because some hospitals were evaluated recently and others some years ago, including differences  between  hospitals  regarding  exclusivebreastfeeding.\n\n2.  To identify the main determinants for the lack ofcompliance with step 6 (no food or drink otherthan breast milk). Thus, we examined to what extent differences between the 28 Baby-FriendlyHospitals in the prevalence of exclusively breastmilk fed infants were associated with  differentlevels of hospital staff compliance with  otherBFHI steps, or how far differences could be ex-plained by different patient mixes.\n\n3.  To determine whether compliance with steps 4, 6,7, and 9 changed following the introduction of themonitoring.","Of all infants, 97% were initially breastfed, but only 38% were exclusively breast milk fed in Baby-Friendly maternity wards,and proportions varied from 8% to 85% among hospitals. \n\nThe strongest determinants for exclusive breastfeeding were health facility factors. \n\nLarge differences werefound between health facilities, and compliance with step 7 (rooming-in) as well as step 6 was unsatisfactory in many of them.\n\nFurthermore, exclusive breastfeeding rates significantly increased with every month of monitoring duration. The findings suggest that theintroduction of continuous monitoring of infant nutrition and related health care practices might have a positive effect on breastfeeding management in health facilities."]
["Do Baby-Friendly Hospitals Influence Breastfeeding Duration on a National Level?","Pediatrics","Merten, S., J. Dratva, and U. Ackermann-Liebrich. “Do Baby-Friendly Hospitals Influence Breastfeeding Duration on a National Level?” Pediatrics 116, no. 5 (2005): e702-8. https://doi.org/10.1542/peds.2005-0537.",2005,"Switzerland","Hospital","BHFI overall/all steps ","Postpartum women","This study reports results of a national study of the prevalence and duration of breastfeeding in 2003 throughout Switzerland and analyzes the influence of compliance with UNICEF guidelines of the hospital where delivery took place on breastfeeding duration.","In 2003, the median duration of any breastfeeding was 31 weeks at the national level, compared with 22 weeks in 1994, and the median duration of full breastfeeding was 17 weeks, compared with 15 weeks in 1994. \n\nThe proportion of exclusively breastfed infants 0 to 5 months of age was 42% for infants born in baby-friendly hospitals, compared with 34% for infants bornelsewhere. \n\nBreastfeeding duration for infants born in baby-friendly hospitals, compared with infants born inother hospitals, was longer if the hospital showed goodcompliance with the UNICEF guidelines (35 weeks vs 29 weeks for any breastfeeding, 20 weeks vs 17 weeks for full breastfeeding, and 12 weeks vs 6 weeks for exclusive breastfeeding).\n\nOnly for the duration of any breastfeeding could a positive effect be seen if delivery occurred in a baby-friendly hospital with high compliance with the UNICEF guide-lines. \n\nKnown factors involved in the evaluation of baby-friendly hospitals showed the expected influence, on the individual level, on duration of exclusive, full, and any breastfeeding. If a child had been exclusively breastfed in the hospital, the median duration of exclusive, full, and any breastfeeding was considerably longer than the mean for the entire population or for those who had received water-based liquids or supplements in the hospital. \n\nA positive effect on breastfeeding duration could be shown for full rooming in, first suckling within 1 hour, breastfeeding on demand, and also the much-debated practice of pacifier use. \n\nAfter controlling for medical problems before, during, and after delivery, type ofdelivery, well-being of the mother, maternal smoking,maternal BMI, nationality, education, work, and income, all of the factors were still significantly associated withthe duration of full, exclusive, or any breastfeeding.\n\nThe fact that breastfeeding rates have generally improved even in nonâ€“baby-friendly health facilities may be indirectly influenced by the BFHI; its publicity and training programs for health professionals have raised public awareness of the benefits of breastfeeding, and the number of professional lactation counselors has increased continuously."]
["Midwivesâ€™ perceptions of skin-to-skin contact between the mother and baby after birth in selected rural primary healthcare facilities in Schoonoord, Limpopo province, South Africa ","African Journal for Physical Activity and Health Sciences ","Mgolozeli, S. E., N. H. Shilubane, and L. B. Khoza. “Midwives’ Perceptions of Skin-to-Skin Contact between the Mother and Baby after Birth in Selected Rural Primary Healthcare Facilities in Schoonoord, Limpopo Province, South Africa.” African Journal for Physical Activity and Health Sciences 24, no. 3 Supplementary (2018): 28–39.",2018,"South Africa","Rural primary care centres","Step 4","Health workers"," The purpose of the study was to explore and describe the perceptions of midwives regarding the implementation of skin-to-skin contact between the mother and baby after birth in selected primary health care facilities in Schoonoord, Makhuduthamaga Sub-district of the  Limpopo province,  South  Africa","Three themes emanated from the study, namely: awareness about skin-to-skin benefits, facilitating factors for successful implementation of skin-to-skin and perceived barriers to the practice of skin-to-skin during birth.\n\nThe participants reported several factors that hamper the implementation of mother-infant skin-to-skin contact in their facilities. They argued that as much as they would love to adhere to the  recommendations of UNICEF (2011) for mother-baby friendly care, there are still limitations such as inadequate knowledge, negative attitudes, working with non-cooperative mothers and lack of motivation.\n\nMidwives reported that there are many factors that could facilitate the successful implementation of  skin-to-skin contact such as positive staff attitudes, continuous health education and in-service training,  and teamwork amongst healthcare professionals.\n\n"]
["One Step for a Hospital, Ten Steps for Women: African American Womenâ€™s Experiences in a Newly Accredited Baby-Friendly Hospital","Journal of Human Lactation","Miller, E. M., A. F. Louis-Jacques, T. F. Deubel, and I. Hernandez. “One Step for a Hospital, Ten Steps for Women: African American Women’s Experiences in a Newly Accredited Baby-Friendly Hospital.” J Hum Lact 34, no. 1 (2018): 184–91. https://doi.org/10.1177/0890334417731077.",2018,"United States","Hospital","BHFI overall/all steps ","Postpartum women","This study aimed to explore African American women's experiences of the Ten Steps to Successful Breastfeeding at a women's center associated with a university-affiliated hospital that recently achieved Baby-Friendly status.","Three key themes emerged from the women's interviews: (a) An appreciation of long-term relationships with medical professionals is evident at the women's center; (b) considerable lactation problems exist postpartum, including lack of help from Baby-Friendly Hospital Initiative sources; and (c) mothers' beliefs about infant autonomy may be at odds with the Ten Steps to Successful Breastfeeding."]
["Follow-up to the baby friendly hospital initiative in two hospitals of the Mexican Social Security Institute","PerinatologÃ­a y ReproducciÃ³n Humana","Monroy-Azuara, M. G., G. S. Arciga-Vazquez, E. N. Cano-Vazquez, S. Mendez-Martinez, G. Islas-Hernandez, M. S. Rodriguez-Ramirez, D. Vargas-Ramirez, and R. Z. Arroyo-Garcia. “Follow-up to the Baby Friendly Hospital Initiative in Two Hospitals of the Mexican Social Security Institute.” Perinatologia y Reproduccion Humana 35, no. 1 (2021): 17–22. https://doi.org/10.24875/PER.19000085.",2021,"Mexico","Hospital","BHFI overall/all steps ","Hospitals","evaluating the compliance of the two certified hospitals in the state of Puebla with Baby Friendly Initiative","Steps 1 and 7 were different between the hospitals with p = 0.010 and p = 0.023, respectively. In the follow-up, General Zone Hospital No. 5 kept steps 1, 2, 3, 7, 8, and 9 above 85%, while those who did not were steps 4, 5, 6, and 10, p = 0.37. Steps of General Hospital No. 15 that remained over 85% were 1, 3, 7, and 9; those that oscillated over time with a <85% rating were steps 2, 4, 5, 6, 8, and 10, p = 0.003."]
["Implementing Baby Friendly Hospital Initiative policy: the case of New Zealand public hospitals","International Breastfeeding Journal","Moore, T., R. Gauld, and S. Williams. “Implementing Baby Friendly Hospital Initiative Policy: The Case of New Zealand Public Hospitals.” Int Breastfeed J 2 (2007): 8. https://doi.org/10.1186/1746-4358-2-8.",2007,"New Zealand","Hospital","Steps 1, 2","Health workers","This article reports on an empirical study of government-directed BFHI implementation in the New Zealand public hospital system. It focuses primarily on the barriers encountered through implementing the first Two Steps of the BFHI: developing BFHI policy and communicating it to staff; and providing necessary staff training","Analysis revealed eight themes: the hospitals were in varying stages of BFHI policy development; hospital policy was not necessarily based on government policy; hospital policies were communicated in differing ways and dependent on resources; factors outside of hospital control impacted on capacity to improve breastfeeding rates; and complex organisational matters pose a barrier to educating personnel involved in the birthing process. \n\nThe study also shows that implementation is multi-faceted and complex."]
["Self-reported breast feeding practices and the Baby Friendly Hospital Initiative in Riyadh, Saudi Arabia: prospective cohort study","BMJ Open","Mosher, C., A. Sarkar, A. A. Hashem, R. E. Hamadah, A. Alhoulan, Y. A. AlMakadma, T. A. Khan, A. K. Al-Hamdani, and A. Senok. “Self-Reported Breast Feeding Practices and the Baby Friendly Hospital Initiative in Riyadh, Saudi Arabia: Prospective Cohort Study.” BMJ Open 6, no. 12 (2016): e012890. https://doi.org/10.1136/bmjopen-2016-012890.",2016,"Saudi Arabia","Hospital","BHFI overall/all steps ","Health workers and postpartum women","This study aimed to examine reported experiences and views on breastfeeding of women using prenatal and postnatal services, and opinions of staff, in the context of the BFHI programme in Riyadh, Saudi Arabia.","Most BFHI-hospital participants (77.9%, n=8 for thisquestion) acknowledged seeing the breast feeding policy compared to 23.5% (n=23) at the non-BFHI-hospital (p<0.01). Breast feeding education and encouragement was higher at the BFHI-hospital (93.3%) compared to the non-BFHI-hospital (48.2%;p<0.01). At postpartum discharge, 51% (n=53) of mothers in the BFHI-hospital were breast feeding exclusively versus 29.6% (n=29) at the non-BFHI-hospital. Where formula feed was introduced, women in the BFHI-hospital more often practiced mixed feeding rather than exclusive formula feeding with some switching from mixed feeding to exclusive breastfeeding between 3 and 6 months postpartum. \n\nExclusive breast feeding rates declined in both hospitals at 3 and 6 months postpartum with lack of community services for lactation being a major reason. \n\nAlthough BFHI-hospital staff (n=9) were more conversant with BFHI principles, defects in adherence to the BFHI 10 Steps were identified"]
["The Impact in the United States of the Baby-Friendly Hospital Initiative on Early Infant Health and Breastfeeding Outcomes","Breastfeeding Medicine","Munn, A. C., S. D. Newman, M. Mueller, S. M. Phillips, and S. N. Taylor. “The Impact in the United States of the Baby-Friendly Hospital Initiative on Early Infant Health and Breastfeeding Outcomes.” Breastfeed Med 11, no. 5 (2016): 222–30. https://doi.org/10.1089/bfm.2015.0135.",2016,"United States","Hospital","BHFI overall/all steps ","Newborns ","To examine updated evidence for the impact of the BFHI in the United States  on  early  infant  health  outcomes  and  breastfeeding outcomes to determine strengths and limitations of the initiative,  along  with  gaps  in  service  for  U.S.  mothers  and infants."," Breast-feeding duration also appears to increase when mothers have increased exposure to Baby-Friendly practices, but deficiencies in breastfeeding tracking mechanisms have limited reliable breastfeeding duration data. Of the 10steps of the BFHI, step 3, prenatal education and step 10, postnatal breastfeeding support are the most difficult steps  to  implement;  however,  those  steps  have  the  potential  to  significantly  impact  maternal  breastfeeding decisions"]
["Factors Influencing Southeastern U.S. Mothersâ€™ Participation in Baby-Friendly Practices: A Mixed-Methods Study","Journal of Human Lactation","Munn, A. C., S. D. Newman, S. M. Phillips, M. Mueller, and S. N. Taylor. “Factors Influencing Southeastern U.S. Mothers’ Participation in Baby-Friendly Practices: A Mixed-Methods Study.” J Hum Lact 34, no. 4 (2018): 821–34. https://doi.org/10.1177/0890334417750143.",2018,"United States","Hospital","BHFI overall/all steps ","Newborns and postpartum women","This study aimed to determine factors influencing southeastern U.S. mothers' participation in Baby-Friendly practices and breastfeeding decisions.","Rural-dwelling and African American mothers had greater odds of nonparticipation in Baby-Friendly practices relative to other groups (odds ratios = 5 and 10, respectively; pâ‰¤ .01). \n\nMothers who received lactation consultation and had moderate (15-44 min) or completed (â‰¥ 45 min) skin-to-skin contact had greater odds of participation in Baby-Friendly practices (both odds ratios â‰¥ 17.5; p < .05). \n\nDirected content analysis revealed six themes: maternal desire to breastfeed, infant state, maternal state, milk supply concerns, provider support, and access to breastfeeding equipment and support services."]
["Good practices in perinatal care andbreastfeeding protection during the firstwave of the COVID-19 pandemic: a nationalsituation analysis among BFHI maternityhospitals in Spain","International Breastfeeding Journal","Muñoz-Amat, B., C. R. Pallás-Alonso, and M. T. Hernández-Aguilar. “Good Practices in Perinatal Care and Breastfeeding Protection during the First Wave of the COVID-19 Pandemic: A National Situation Analysis among BFHI Maternity Hospitals in Spain.” Int Breastfeed J 16, no. 1 (2021): 66. https://doi.org/10.1186/s13006-021-00407-y.",2021,"Spain","Hospital","BHFI overall/all steps ","Postpartum women","To analyse the impact of the COVID-19 pandemic on perinatal care and breastfeeding support practices offered by the Spanish maternity hospitalscommitted to the UNICEF Baby-friendly Hospital Initiative (BFHI), to women with and without COVID-19"," Mothers with COVID-19 suffered greater restrictions in the practicescompared to women without COVID-19, with lower rates of companion of choice during labour (84% vs 100%;p=0.003), skin-to-skin contact (32% vs 52%;p= 0.04), rooming-in (74% vs 98%;p< 0.001), companion of choice duringhospital stay (68% vs 90%;p= 0.006), and breastfeeding support (78% vs 94%;p= 0.02). Practices were significantlyless prevalent in COVID-19 mothers compared to pre-pandemic situation. A lower accompaniment rate wasobserved in non-COVID-19 group during delivery (24% vs 47.9%;p< 0.01). Hospitals with higher commitment toBFHI practices reported higher rates of skin-to-skin contact (45.2% vs 10.5%;p= 0.01) and rooming-in (83.9% vs57.9%;p< 0.05) in COVID mothers. Fewer restrictions were observed in hospitals located in the regions where thepandemic hit harder. In these regions there was a significantly higher level of BFHI commitment of the hospitals,but no significant differences were observed in the average size of the hospital. All the practices suffered evenmore restrictions during the first weeks of the pandemic."]
["Feeding Rates in Baby-Friendly and Non-Baby-Friendly Hospitals in the Czech Republic From 2000","Journal of Human Lactation","Mydlilova, A., A. Sipek, and J. Vignerova. “Breastfeeding Rates in Baby-Friendly and Non-Baby-Friendly Hospitals in the Czech Republic from 2000 to 2006.” J Hum Lact 25, no. 1 (2009): 73–78. https://doi.org/10.1177/0890334408325820.",2009,"Czech Republic","Hospital","BHFI overall/all steps ","Newborns ","To evaluate the type of infant feeding used after maternity hospital discharge in the Czech Republic from 2000 to 2006, to compare the situation in BF and non-BF hospitals, and to access the breastfeeding rates in perinatal centers (PCs) and neonatal intermediate care units (NICUs) where the majority of high-risk infants are concentrated. ","- The exclusive breastfeeding rates in BFH decreased to 90.3% in 2006 from 92.9% in 2000. \n- In non-BFH breastfeeding rates lowered to 87.6% in 2006 from 89.4% in 2000. \n- Partial breastfeeding increased in both BFH  and non-BFH.  \n- 22.3% of infants were born in BFH whereas in 2006. \n- 63.9% of infants were born in BFH. The risk of infants not being exclusively breastfed was higher in non-BFH. \n- From the beginning of the BFHI implementation, the rates of exclusive breastfeeding has increased from 83.6% in 1993 to 90.5% in 2000. \n- Rates fell from 2002 to 2006. \n- The adherence to the 10 Steps varies across hospitals. "]
["Factors Impacting Breastfeeding and Milk Expression in the Neonatal Intensive Care Unit","International Journal of Caring Sciences ","Naylor, Lindsay, and Abigail Clarke-Sather. “Factors Impacting Breastfeeding and Milk Expression in the Neonatal Intensive Care Unit.” International Journal of Caring Sciences 13, no. 2 (2020): 970–81.",2020,"United States","Hospital","BHFI overall/all steps ","Newborns and postpartum women","This  study  analyzes  the  impact  of  intention  to  breastfeed  and  Baby-Friendly  Hospital  Initiative (BFHI) designation on breastfeeding and milk expression duration when infants require NICU care.","Mothers who intended to breastfeed breastfed for an average of 15.8 months and 11 months. This difference in duration was statistically significant when compared to mothers who did not intend to breastfeed only breastfed for an average of 2.2 months nursing and 2.6 months expressing milk. The BFHI designation did not significantly influence the amount of time the mothers breastfed for or expressed milk."]
["Impact of the Baby Friendly Hospital Initiative (BFHI) Programme on Breast-Feeding Knowledge, Attitude and Practices of Mothers","Pakistan Journal of Nutrition","Ndiokwelu, C. I., O. I. C. Nwosu, P. N. Ani, A. O. Chizike, and M. A. Nwabugo. “Impact of the Baby Friendly Hospital Initiative (BFHI) Programme on Breast-Feeding Knowledge, Attitude and Practices of Mothers.” Pakistan Journal of Nutrition 15, no. 3 (2016): 244–48. https://doi.org/10.3923/pjn.2016.244.248.",2016,"Nigeria","Hospital","BHFI overall/all steps ","Postpartum women","To investigate the impact of the baby friendly hospital initiative programme on the breast-feeding knowledge, attitude and practices of mothers attending Mother of Christ Specialist Hospital, Enugu. ","There is an evident gap between the knowledge and practice of exclusive breast-feeding. The majority (86.3%) of the mothers believed breastfeeding to be beneficial and 61.6% said there was no disadvantages to exclusive breastfeeding. 74% of participants got their information from nurses. The study revealed the positive impact of the BFHI on a mother's attitude and knowledge. This is expected as the mothers attended a BFH. However only 19.3% of mothers initiated breastfeeding within 30 minutes of birth. Majority of mothers were aware of the benefits of colostrum. This study demonstrated the weak influence of the BFHI as only 31.5% of mothers exclusively breastfed for 6 months. "]
["The Extent that Noncompliance with the Ten Steps to Successful Breastfeeding Influences Breastfeeding Duration","Journal of Human Lactation","Nickel, N. C., M. H. Labbok, M. G. Hudgens, and J. L. Daniels. “The Extent That Noncompliance with the Ten Steps to Successful Breastfeeding Influences Breastfeeding Duration.” J Hum Lact 29, no. 1 (2013): 59–70. https://doi.org/10.1177/0890334412464695.",2013,"United States","Hospital","BHFI overall/all steps ","Postpartum women","Examine how noncompliance with each of the Steps, and combinations of 2 Steps, influence duration of breastfeeding at the breast.","A vast amount of maternity care practices in the US do not include all ten steps. This could be as a result of the poor establishment of the physiological feedback systems that provide support for sustained breastfeeding. When there are steps lacking there is compromisation of breastfeeding at the breast. "]
["Investigation   of   the   Effect   of   Training   on   Promoting Breast-feeding   at   Baby-Friendly   Hospital Case   Study; Tohid Hospital in Jam, Bushehr","IranianJournal of Neonatology","Nickkhaha, A. “Investigation of the Effect of Training on Promoting Breast-Feeding at Baby-Friendly Hospital Case Study; Tohid Hospital in Jam, Bushehr.” Iranian Journal of Neonatology 6, no. 2 (2015): 24–31.",2015,"Iran","Hospital","BHFI overall/all steps ","Newborns and postpartum women","Assess  a  baby-friendly  hospital to   evaluate   its   role   in   promoting   the   breast-feeding."," Careful monitoring of BFH, breastfeeding support services and breastfeeding training by midwives are extremely important in the training of mothers on the importance of breastfeeding."]
["Breastfeeding in Crisis: Survey Results of the Baby-Friendly Hospital Initiative","Curationis","Nikodem, C., L. Schelke, L. Enraght-Moony, and G. J. Hofmeyr. “Breastfeeding in Crisis: Survey Results of the Baby-Friendly Hospital Initiative.” Curationis 18, no. 3 (1995): 39–42. https://doi.org/10.4102/curationis.v18i3.1361.",1993,"South Africa","Hospital","BHFI overall/all steps ","Health workers and postpartum women","To determine the degree of implementation of the \"Ten  Steps  to  Successful  Breastfeeding\"  in South African hospitals.","A small portion of hospital that participated had a written breastfeeding policy.\n\nThere is a shortage of specialized training in supporting breastfeeding.\n\nThere was a low response rate, there is a need for further evaluation to achieve an accurate reflection of the hospital's attitudes and values towards the necessity of a breastfeeding policy."]
["Baby-Friendly Hospital Initiative and Breastfeeding Among WIC-Participating Infants in Los Angeles County","Journal of Human Lactation","Nobari, T. Z., L. Jiang, M. C. Wang, and S. E. Whaley. “Baby-Friendly Hospital Initiative and Breastfeeding Among WIC-Participating Infants in Los Angeles County.” J Hum Lact 33, no. 4 (2017): 677–83. https://doi.org/10.1177/0890334417716118.",2017,"United States","Community ","BHFI overall/all steps ","Newborns and postpartum women","To determine whether the BFHI effort has had a beneficial effect on Baby-Friendly hospital practices in LAC hospitals and to determine if birthing hospitals' Baby-Friendly designation status is associated with breastfeeding outcomes among WIC-participating children in LAC.","- There has been an improvement in the rates of BFH practices since 2008. \n- Babies that were born in a designated Baby-Friendly Hospital or that was in the process of obtaining the BFH status were more likely to be exclusively breastfed at 1 and 3 months. "]
["Expansion of the Baby-Friendly Hospital Initiative Ten Steps to Successful Breastfeeding into Neonatal Intensive Care: Expert Group Recommendations","Journal of Human Lactation","Nyqvist, K. H., A. P. Haggkvist, M. N. Hansen, E. Kylberg, A. L. Frandsen, R. Maastrup, A. Ezeonodo, L. Hannula, and L. N. Haiek. “Expansion of the Baby-Friendly Hospital Initiative Ten Steps to Successful Breastfeeding into Neonatal Intensive Care: Expert Group Recommendations.” Journal of Human Lactation 29, no. 3 (2013): 300–309. https://doi.org/10.1177/0890334413489775.",2013,"International policy","Neonatal care policy","BHFI overall/all steps ","Health workers and postpartum women and their babies ","To investigate the different situations faced by preterm and sick infants and their mothers, compared to healthy infants and their mothers and the need for a specific breastfeeding policy for neonatal intensive care and require that health care professionals have knowledge and skills in lactation and breastfeeding support, including provision of antenatal information, that are specific to neonatal care.","There are various differences between preterm and sick infants and their mothers related to lactation, breastfeeding, and feeding, as well as between settings in levels of medical-technical neonatal care and the care that families have access to.\n- It is difficult to specify standards that are required for high-quality lactation and breastfeeding support in neonatal intensive care units that can be equally applied everywhere."]
["Application of the Baby Friendly Hospital Initiative to Neonatal Care: Suggestions by Swedish Mothers of Very Preterm Infants","Journal of Human Lactation","Nyqvist, K. H., and E. Kylberg. “Application of the Baby Friendly Hospital Initiative to Neonatal Care: Suggestions by Swedish Mothers of Very Preterm Infants.” J Hum Lact 24, no. 3 (2008): 252–62. https://doi.org/10.1177/0890334408319156.",2008,"Sweden","Neonatal care policy","BHFI overall/all steps ","Postpartum women","The aim of this study was to obtain suggestions from mothers of very preterm infants regarding modification of the Baby Friendly Hospital Initiative (BFHI) 10 Steps to Successful Breastfeeding","- only 1 mother had stayed in a parent room for multiple days prior to going home.\n- mothers started breastfeeding at a median PMA of 31 weeks, at an age of 11 days.\n- Infants were initially fed through an orogastric tube. \n- 10 were supplemented by cup and 3 were bottle fed the mothers expressed milk. \n- mothers complained that step 1 was not applied as they received little information that parents should be routinely informed about the policy. "]
["BREAST FEEDING PRACTICES IN URBAN AND RURAL HEALTH CENTRES: IMPACT OF BABY FRIENDLY HOSPITAL INITIATIVE IN ILE-IFE, NIGERIA","Nutrition and Health","Ojofeitimi, E. O., O. A. Esimai, O. O. Owolabi, Oluwabusi, O. F. Olaobaju, and T. O. Olanuga. “Breast Feeding Practices in Urban and Rural Health Centres: Impact of Baby Friendly Hospital Initiative in Ile-Ife, Nigeria.” Nutr Health 14, no. 2 (2000): 119–25. https://doi.org/10.1177/026010600001400204.",1993,"Nigeria","Hospital","BHFI overall/all steps ","Postpartum women","to assess the impact of the Baby Friendly Hospital Initiative (BFHI) on breast feeding practices.","-The majority of those that initiated breastfeeding within 30 minutes after birth were from a designated BFHI.\n- Those with higher education were more likely to commit to exclusive breastfeeding. \n- There was a significant increase in exclusive breastfeeding that was once thought to be at 3% is now at 61%. \n- The BFHI has had a greater impact on the urban areas whereas the impact is yet to be felt in the rural areas. "]
["Knowledge, attitude and practice of health workersin Keffi local government hospitals regardingBaby-Friendly Hospital Initiative (BFHI) practices","European Journal of Clinical Nutrition ","Okolo, S. N., and C. Ogbonna. “Knowledge, Attitude and Practice of Health Workers in Keffi Local Government Hospitals Regarding Baby-Friendly Hospital Initiative (BFHI) Practices.” Eur J Clin Nutr 56, no. 5 (2002): 438–41. https://doi.org/10.1038/sj.ejcn.1601331.",2002,"Nigeria","Hospital","BHFI overall/all steps ","Health workers","To assess the knowledge, attitude and practice of health workers towards Baby Friendly Hospital Initiative (BFHI)practices and thereafter plan an advocacy on BFHI training of the workers.","- Only 20.8% of health workers were aware of the need to initiate BF within 30 mins of delivery.\n- Only 5.25% of workers could demonstrate how to correctly position and attach a baby.\n-  there was a general lack of awareness in the hospitals of the major recommended practices that promote and sustain BF."]
["Breastfeeding in Iran: prevalence, duration and current recommendations","International Breastfeeding Journal","Olang, B., K. Farivar, A. Heidarzadeh, B. Strandvik, and A. Yngve. “Breastfeeding in Iran: Prevalence, Duration and Current Recommendations.” Int Breastfeed J 4 (2009): 8. https://doi.org/10.1186/1746-4358-4-8.",2009,"Iran","Community ","BHFI overall/all steps ","Newborns (Infants under 24 months)","The aim of this study was to investigate prevalence, duration and promotion of breastfeeding status in Iran with respect to the Baby Friendly Hospital, government actions and activities by the Breastfeeding Promotion Society including comparison with European countries.","- Nationally, 90% and 57% of infants that were one and two years of age were breastfed.\n- In rural areas exclusive breastfeeding rates were 58% and 29% at 4 and 6 months.\n- In urban areas exclusive breastfeeding rates were 56% and 27%.\n- 80% of births in 2006 were in accredited BF hospitals. \n- Iran has adopted the WHO International code of marketing of breastmilk substitutes in since 1991. "]
["Cost-effectiveness analysis of Baby-Friendly Hospital Initiative inpromotion of breast-feeding and reduction of late neonatal infantmortality in Brazil","Public Health Nutrition","Oliveira Silva, O. L. de, M. F. Rea, F. M. Sarti, and G. Buccini. “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 24, no. 8 (2021): 2365–75. https://doi.org/10.1017/S1368980020001871.",2020,"Brazil","Hospital","BHFI overall/all steps ","Newborns and postpartum women","To analyse the cost-effectiveness of Baby-Friendly Hospital Initiative(BFHI) in promoting breast-feeding during the first hour of life (BFFHL) and reducing late neonatal mortality.","Cost-effectiveness analysis showed that BFHI was highly cost-effective inraising BFFHL by 32·0 % at lower cost in comparison with non-BFHI. In addition, BFHI was cost-effective in reducing late neonatal mortality rate by 13·0 % from allcauses and by 13·1 % of infant mortality rate from infections.\n\nBased on findings of the current study, considering estimate of deaths avoided by BFHI between 7 and 28 d after birth (forty-nine deaths averted), late neonatal mortality rate could be reduced to approximately 1·96 per thousand in the municipality during 2016 due to adoption of BFHI in all hospitals, representing a reduction of 13 % in this infant mortality rate component"]
["A breastfeeding support program changed breastfeeding patterns but did not affect the mothersâ€™ self-efficacy in breastfeeding at two months ","Early Human Development","Oras, P., T. Ljungberg, L. Hellström-Westas, and E. L. Funkquist. “A Breastfeeding Support Program Changed Breastfeeding Patterns but Did Not Affect the Mothers’ Self-Efficacy in Breastfeeding at Two Months.” Early Hum Dev 151 (2020): 105242. https://doi.org/10.1016/j.earlhumdev.2020.105242.",2020,"Sweden","Hospital","Becoming/pre BFHI","Postpartum women","To describe breastfeeding patterns in 2-month-old infants before and after the implementation of a breastfeeding support program. A secondary aim was to investigate the relationship between breastfeeding patterns and the mother's self-efficacy in breastfeeding.","- Patterns of on demand breastfeeding were more common in the intervention group (97.5%), compared to 74.4% in the baseline group. \n- Breastfeeding was more frequent in the intervention group, median 14 times per 24hrs compared to 11 times in the baseline group. "]
["Comparing breast feeding practices in Baby Friendly and non-accredited hospitals in Salvador, Bahia","Rev. Bras. SaÃºde Matern. Infant., Recife","Ortiz, P. N., R. B. Rolim, M. F. Lima e Souza, P. L. Soares, T. de O. Vieira, G. O. Vieira, P. P. R. Lyra, and L. R. Silva. “Comparing Breast Feeding Practices in Baby Friendly and Non-Accredited Hospitals in Salvador, Bahia.” Revista Brasileira de Saude Materno Infantil 11, no. 4 (2011): 405–13. https://doi.org/10.1590/S1519-38292011000400007.",2011,"Brazil","Hospital","BFHI and non-BFHI","Postpartum women","To compare compliance with Steps 4to 10 of 'The Steps to Successful Breastfeeding'\u009d in two  hospitals  accredited  by  the  Baby-Friendly Hospital Initiative (BFHI group) with two not yet accredited hospitals in Salvador.","- Statistically significant differences were found regarding step 5, 6, 8 and 9 between the accredited and non accredited BFHI. \n- There was no difference reported regarding step 4, 7 or 10.\n- the benefits of BFHI were highlighted in the results of this study. "]
["Effectiveness of a Breastfeeding Self-efficacy Intervention: Do Hospital Practices Make a Difference?","Matern Child Health Journal","Otsuka, K., M. Taguri, C. L. Dennis, K. Wakutani, M. Awano, T. Yamaguchi, and M. Jimba. “Effectiveness of a Breastfeeding Self-Efficacy Intervention: Do Hospital Practices Make a Difference?” Matern Child Health J 18, no. 1 (2014): 296–306. https://doi.org/10.1007/s10995-013-1265-2.",2014,"Japan","Hospital","BHFI overall/all steps ","Prenatal:  Pregnant women in their 3rd trimester","To  evaluate  the  effect  of  a  self-efficacy  intervention   on   breastfeeding   self-efficacy   and   exclusive breastfeeding,  and  further  assessed  the  difference  in  its effect  by  hospital-routine  type. ","- In non-BFHs there was no positive effect noted on breastfeeding self-efficacy or the rate of exclusive breastfeeding 4 week postpartum.\n- In BFHs the intervention improved breastfeeding self-efficacy and exclusive breastfeeding 4 weeks postpartum. \n- In non-BFHs supplementation was provided and for the majority of cases the mother and infant were separated.\n- 12 week infant feeding status did not improve in either hospital type.\n-The intervention improved breastfeeding self-efficacy and exclusive breastfeeding at 4 weeks post-partum only in the BFHs. "]
["Knowledge and attitudes of Lebanese women towards Baby Friendly Hospital Initiative practices","PLOS ONE","Oueidat, H., L. Charafeddine, H. Nimer, H. Hussein, and M. Nabulsi. “Knowledge and Attitudes of Lebanese Women towards Baby Friendly Hospital Initiative Practices.” PLoS One 15, no. 9 (2020): e0238730. https://doi.org/10.1371/journal.pone.0238730.",2020,"Lebanon","Hospital","BHFI overall/all steps ","Prenatal women","To assess the knowledge of Lebanese women of BFHI steps, and to explore their attitudes towards Baby Friendly Hospitals, Skin-to-Skin Contact and Kangaroo Care practices.","- Majority of participants were unfamiliar with the terms of the Baby Friendly hospital, inadequately instructed on how to initiate. \n- When given information on the BFHI and the benefits more than 90% of mothers said that they would deliver in BFH. "]
["Previous BFHI training and nurses knowledge, attitudes and practices regarding exclusive breastfeeding  ","Afr. J. Med. Sci ","Owoaje, E. T., A. Oyemade, and O. O. Kolude. “Previous BFHI Training and Nurses’ Knowledge, Attitudes and Practices Regarding Exclusive Breastfeeding.” Afr J Med Med Sci 31, no. 2 (2002): 137–40.",2002,"Nigeria ","Hospital","BHFI overall/all steps ","Health workers","To assess the effect of BFHI training on knowledge, attitudes and support practices of nurses with regards to exclusive BF in Nigeria. ","Significantly higher proportions of the BFHI trained nurses has the knowldege regarding the causes and management of common BF problems.\n-@ overall knowledge scores of the BFHI trained nurses was significantly higher than that of the untrained.\n-@ higher proportions of BFHI trained nurses reported correct support practices for the initiation and establishment of exclusive BF amongst mothers."]
["Positive Effect of Baby-Friendly Hospital Initiatives on Improving Mothers' Intention for Successful Breastfeeding in Korea","Journal of Korean Medical Science","Park, H. W., K. H. Ryu, Y. Piao, P. Li, J. S. Hong, H. B. Kim, H. Chung, J. K. Hoh, and Y. J. Kim. “Positive Effect of Baby-Friendly Hospital Initiatives on Improving Mothers’ Intention for Successful Breastfeeding in Korea.” J Korean Med Sci 33, no. 43 (2018): e272. https://doi.org/10.3346/jkms.2018.33.e272.",2018,"Korea","Hospital","BHFI overall/all steps ","Prenatal women","To identify an antenatal strategy for initiation and continuation of human BF, and to identify how Baby-Friendly Hospitals (BFHs) may positively influence the intention to breastfeed","Room-in care, greater awareness of the advantages to BF infants and mothers, participating in the antenatal education programs and the provision of BF facilities showed a positive association with plans for exclusive breastfeeding.\n- those who planned to give birth in BFHs also wanted to initiate breastfeeding immediately after birth, in-@room care and had a wider understanding of the benefits of BF."]
["10 Years after Baby-Friendly Designation: Breastfeeding Rates Continue to Increase in a US Neonatal Intensive Care Unit","Journal of Human Lactation","Parker, M., L. Burnham, J. Cook, E. Sanchez, B. L. Philipp, and A. Merewood. “10 Years after Baby-Friendly Designation: Breastfeeding Rates Continue to Increase in a US Neonatal Intensive Care Unit.” J Hum Lact 29, no. 3 (2013): 354–58. https://doi.org/10.1177/0890334413489374.",2013,"United States","Hospital","BHFI overall/all steps ","Newborns and postpartum women","To determine the rate of breastfeeding initiation and continuation in a US, inner-city, level 3 NICU 10 years after Baby-Friendly designation.","- The initiation of breastfeeding increased from 74% to 85% between 1999 and 2009.\n- Any breast milk at two weeks of age increased to 80% from 66%. \n\n"]
["Influence of the support offered to breastfeeding by maternity hospitals","Rev SaÃºde PÃºblica","Passanha, A., M. H. Benício, S. I. Venâncio, and M. C. Reis. “Influence of the Support Offered to Breastfeeding by Maternity Hospitals.” Rev Saude Publica 49 (2015). https://doi.org/10.1590/s0034-8910.2015049005354.",2015,"Brazil","Hospital","Becoming/pre BFHI","Newborns (Infants up to 6 months)","To evaluate whether the support offered by maternity hospitals is associated with higher prevalence of exclusive and predominant breastfeeding","Where the number of Steps fulfilled was higher there was a Tendency for predominant breastfeeding to be more prevalent.\n-  the Step that encourages mothers towards the establishment of breastfeeding support groups and the Step that encouraged mothers not to use artificial teats or pacifiers to breast feed infants were associated with a higher prevalence of exclusive breastfeeding."]
["The effect of Babyâ€\u0090friendly status on exclusive breastfeeding in U.S. hospitals","Maternal and Child Nutrition","Patterson, J. A., N. S. Keuler, and B. H. Olson. “The Effect of Baby-Friendly Status on Exclusive Breastfeeding in U.S. Hospitals.” Matern Child Nutr 14, no. 3 (2018): e12589. https://doi.org/10.1111/mcn.12589.",2018,"United States","Hospital","BFH and non-BFH","Records (published EBF rates)"," The purpose of this study was to examine the relationships between population demographics and the Baby‐friendly (BF) hospital designation on EBF rates in hospitals throughout the United States. We obtained EBF rates from 121 BF hospitals and 1,608 hospitals without the BF designation. Demographic variables were computed using census tract data for the population surrounding each hospital. Relationships were explored using linear regression. ","In 2014, a leading hospital accreditation agency, mandated hospitals publicly report their exclusive breastfeeding (EBF) rates. This new regulation provided an opportunity to explore differences in EBF outcomes using a standardized definition across a large hospital sample in the United States.\nWe found that EBF rates were positively correlated with a bachelor's degree, log income, and those who identified as White or Asian and negatively correlated with those without college attendance, individuals living below the poverty line, and those who identified as African American or Hispanic. For all models, the BF designation of a hospital was associated with higher EBF rates (p < 0.01; effect sizes, 0.11–0.49) with the exception of the model containing log income. Using a multiple linear regression model that was allowed to contain more than one independent variable, we were able to explain 22% of the variability in EBF rates. The BF hospital designation was associated with significantly higher EBF rates independent of demographic variables. Support for hospitals to attain the BF hospital designation is a meaningful public health goal."]
["Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review","Maternal & Child Nutrition","Perez-Escamilla, R., J. L. Martinez, and S. Segura-Perez. “Impact of the Baby-Friendly Hospital Initiative on Breastfeeding and Child Health Outcomes: A Systematic Review.” Maternal and Child Nutrition 12, no. 3 (2016): 402–17. https://doi.org/10.1111/mcn.12294.",2016,"19 different countries in South America, North America, Western & Eastern Europe, South Asia, Eurasia and sSAfrica.","Hospital & Community","BHFI overall/all steps ","Postpartum women","To examine the impact of BFHI implementation on breastfeeding and child health outcomes worldwide and in the United States","Adherence to the BFHI Ten Steps has a positive impact on short-term, medium term and long-term breastfeeding (BF) outcomes.\n\nOf the 58 studies that met the systematic review criteria, 55 support this relationship, and none suggest a negative impact of BFHI on BF outcomes.    \n                                                  \nThe Ten Steps that form the basis of Baby-friendly Hospital Initiative (BFHI) serve as a quality assurance system based on highly interrelated specific actions at the facility and community level.    \n                                                          \nThere is a dose-response relationship between the number of BFHI steps women are exposed to and the likelihood of improved BF outcomes (early BF initiation, exclusive breastfeeding EBF at hospital discharge, any BF and EBF duration).\n\nCommunity support (step 10) appears to be essential for sustaining  breastfeeding impacts of BFHI in the longer term.  \n\nAvoiding in-hospital supplementation appears to be a key step for breastfeeding success, perhaps reflecting adequate implementation\nof the rest of Ten Steps\n"]
["Implementation of childhood obesity prevention and control policies in the United States and Latin America: Lessons for cross-border research and practice","Obesity Reviews","Pérez-Escamilla, R., M. Vilar-Compte, E. Rhodes, O. L. Sarmiento, C. Corvalan, R. Sturke, and S. Vorkoper. “Implementation of Childhood Obesity Prevention and Control Policies in the United States and Latin America: Lessons for Cross-Border Research and Practice.” Obes Rev 22 Suppl 3, no. Suppl 3 (2021): e13247. https://doi.org/10.1111/obr.13247.",2021,"United States and Brazil","Hospital","BHFI overall/all steps ","Academic review -148 articles on the BFHI in the United States and Brazil to inform this case study ","The RE-AIM framework enabled a structured and systematic approach to evaluating the implementation of the BFHI in the United States and Brazil while allowing comparison of the experiences ofeach country. ","The adoption and implementation of the Ten Steps acrossmany facilities in these two countries, however, required differentapproaches, given their differing healthcare systems.  The Brazil MOH scaled up the BFHI aAlthough the RE-AIM framework does not include an explicit focuson health equity, we were able to capture information about equityin the implementation of the BFHI. For example, we found thatequity considerations were at the forefront in the United States, asdemonstrated by CDC-led surveillance of breastfeeding rates bystates and sociodemographics and efforts directed toward improvingmaternity care practices to reduce racial/ethnic, income, and geo-graphic disparities in breastfeeding. cross one national health system, whereas the fragmented health system in the United States required activeinvolvement of numerous hospital systems and government and non-governmental agencies from the federal to the county or town level. Finally, both countries established systems for monitoring maternitycare practices and policies related to breastfeeding and ensuredresults were available to facilities, though Brazil employed a self-monitoring process and the US CDC spearheaded monitoring efforts."]
["Sustained Breastfeeding Rates at a US Baby-Friendly Hospital","Pediatrics","Philipp, B. L., K. L. Malone, S. Cimo, and A. Merewood. “Sustained Breastfeeding Rates at a US Baby-Friendly Hospital.” Pediatrics 112, no. 3 Pt 1 (2003): e234-6. https://doi.org/10.1542/peds.112.3.e234.",2003,"United States","Hospital","BHFI overall/all steps ","Newborns ","To establish whether  Baby-Friendly  status  would sustain elevated breastfeeding initiation rates at this US hospital beyond the year of designation. ","- Full implementation and continued use of the \"Ten Steps to Successful Breastfeeding\", the Baby-Friendly Hospital Initiative framework has contributed to the broadening of the positive impact that these have had on breastfeeding rates in US Hospital environments. "]
["Baby Friendly Hospital Initiative practices and breastfeeding duration in a cohort of first-time mothers in Adelaide, Australia","Midwifery","Pincombe, J., P. Baghurst, G. Antoniou, B. Peat, A. Henderson, and E. Reddin. “Baby Friendly Hospital Initiative Practices and Breast Feeding Duration in a Cohort of First-Time Mothers in Adelaide, Australia.” Midwifery 24, no. 1 (2008): 55–61. https://doi.org/10.1016/j.midw.2006.06.009.",2008,"Australia","Hospital","6 steps","Postpartum women","to investigate the relationship between adherence to six of the Baby Friendly Hospital Initiative (BFHI)Ten steps to successful breast feeding and the duration of breast feeding in first-time mothers","Infants that received bottle feed, pacifiers or used a nipple shield during the postnatal stay were at greater risk of weaning."]
["Hospital Staffâ€™s Perceptions with Regards to the Baby-Friendly Initiative: Experience from a Canadian Tertiary Care Centre","Journal of Human Lactation","Pound, C., N. Ward, M. Freuchet, S. Akiki, J. Chan, and S. Nicholls. “Hospital Staff’s Perceptions with Regards to the Baby-Friendly Initiative: Experience from a Canadian Tertiary Care Centre.” Journal of Human Lactation 32, no. 4 (2016): 648–57. https://doi.org/10.1177/0890334416662630.",2016,"Canada","Hospital","Becoming/pre BFHI","Health workers","To explore health care workers' self-reported knowledge of the BFI and their perceptions of the importance of its components.","-16.9% of participants reported to having some knowledge of the BFI\n- 13.5% had knowledge on the ten steps to successful breastfeeding. \n-self-reported knowledge was associated with those that have had children and those who had formal breastfeeding education. \n-75% of participants reported that they felt it was important that their institutions adopt the BFI. "]
["The Social Value of Implementing the Ten Steps to Successful Breastfeeding in an Indonesian Hospital: A Case Study","YALE JOURNAL OF BIOLOGY AND MEDICINE","Pramono, A. Y., J. L. Desborough, J. P. Smith, and S. Bourke. “The Social Value of Implementing the Ten Steps to Successful Breastfeeding in an Indonesian Hospital: A Case Study.” Yale J Biol Med 94, no. 3 (2021): 429–58.",2021,"Indonesia","Hospital","BHFI overall/all steps ","Health facility level","This study aimed to evaluate the monetary value of the social impact of implementing the WHO (1989) Ten Steps in an Indonesian maternity hospital using the Social Return on Investment (SROI) framework","The total per annum value of investment (cost) required to implement Ten Steps in Airlangga University Hospital was US$ 972,303. The estimate yearly benefit was US$ 22,642,661. The social return on the investment in implementing Ten Steps in this facility was calculated to be US$ 49 (sensitivity analysis: US$ 18-65). Thus, for every US$ 1 invested in Ten Steps implementation by Airlangga Hospital could be expected to generate approximately US$ 49 of benefit.This study aimed to evaluate the monetary value of the social impact of implementing the WHO (1989) Ten Steps in an Indonesian maternity hospital using the Social Return on Investment (SROI) framework.\n\nCorrected piece: â€œThese results align with our previous research [40] which demonstrates the positive social value AUD$ 55 or USD$ 37 for every AUD$1 invested (USD$ PPP = AUD$ 1.48) of maintaining the BFHI accreditation in an Australian public hospital.â€\u009d Direct comparison between these two countries is not feasible due to a number of reasons including cultural and health system funding and organization. \n\nCorrected: \"Nevertheless, the greater social return on investment found in this study of implementation of the Ten Steps in Indonesia may further emphasize the additional value that may be achieved through BFHI-accreditation, as mother and baby will have higher benefits as showed by our best-case scenario\"."]
["Social value of maintaining baby-friendly hospital initiative accreditation in Australia:case study","International Jounal for Equity in Health","Pramono, A., J. Smith, J. Desborough, and S. Bourke. “Social Value of Maintaining Baby-Friendly Hospital Initiative Accreditation in Australia: Case Study.” Int J Equity Health 20, no. 1 (2021): 22. https://doi.org/10.1186/s12939-020-01365-3.",2021,"Australia","Other: Country level","BHFI overall/all steps ","Hospital","While more than three in four births in Australia take place in public hospitals, in 2020 only 26% of Australian hospitals were BFHI-accredited. So what is the social return to investing in BFHI accreditation in Australia, and does it incentivize BFHI accreditation? This study aimed to examine the social value of maintaining the BFHI accreditation in one public maternity unit in Australia using the Social Return on Investment (SROI) framework. This novel method was developed in 2000 and measures social, environmental and economic outcomes of change using monetary values.\nAim: to examine the social value of maintainingthe BFHI accreditation in one public maternity unit in Australia using the Social Return on Investment (SROI) framework.","Results: The social return from the BFHI in this facility was calculated to be AU$ 1,375,050. The total investment required was AU$ 24,433 per year. Therefore, the SROI ratio was approximately AU$ 55:1 (sensitivity analysis: AU$ 16–112), which meant that every AU$1 invested in maintaining BFHI accreditation by this maternal and newborn care facility generated approximately AU$55 of benefit. \nConclusions: Scaled up nationally, the BFHI could provide important benefits to the Australian health system and national economy. In this public hospital, the BFHI produced social value greater than the cost of investment, providing new evidence of its effectiveness and economic gains as a public health intervention. Our findings using a novel tool to calculate the social rate of return, indicate that the BHFI accreditation is an investment in the health and wellbeing of families, communities and the Australian economy, as well as in health equity."]
["â€œWe All Believe in Breastfeedingâ€\u009d: Australian Midwivesâ€™ Experience of Implementing the Baby Friendly Hospital Initiative","Journal of Human Lactation","Pramono, A., J. Smith, S. Bourke, and J. Desborough. “‘We All Believe in Breastfeeding’: Australian Midwives’ Experience of Implementing the Baby Friendly Hospital Initiative.” J Hum Lact, 2022, 8903344221106473. https://doi.org/10.1177/08903344221106473.",2022,"Australia","Hospital & Community","BHFI overall/all steps ","Health workers","To explore midwives' experiences of implementing the Baby-Friendly Hospital Initiative in a Baby-Friendly accredited public hospital in","Time as a critical resource, and continuity of care, were cross cutting themes that framed midwives' experiences in supporting mothers to breastfeed their babies. Time constraints were experienced both through the health system structure and the BFHI accreditation process. Despite the challenges, the overarching themeâ€”that we all believe in breastfeeding 'fueled midwives' motivation"]
["BABYFRIENDLYHOSPITALINITIATIVEEXPERIENCESFROMASERVICEHOSPITAL","MJAFI","Raman, T. R., V. Parimala, and A. Iyengar. “Baby Friendly Hospital Initiative Experiences from a Service Hospital.” Med J Armed Forces India 57, no. 1 (2001): 22–25. https://doi.org/10.1016/s0377-1237(01)80084-8.",2001,"India","Hospital","BHFI overall/all steps ","Postpartum women","To assess the practices related to breastfeeding during antenatal, in labour room and post natal ward both  for  the period pre BFHI and post BFHl Programme Initiated at Command Hospital (AirForce)."," the majority of preterm neonates were being given reconstituted milk.\n- mothers that underwent tubectomy were taught to express milk into sterile containers, the Health giver would then feed the neonate with a spoon.\n - in comparison to preBFHI period, neonates that were born during the post-BFHI period have been exclusively breastfed with no difference in growth. However, mothers had notable differences with a reduction in retracted, inverted or sore nipples."]
["Passive resistance: Early experiences of midwifery students/graduates and the Baby Friendly Health Initiative 10 steps to successful breastfeeding","Women and Birth ","Reddin, E., J. Pincombe, and P. Darbyshire. “Passive Resistance: Early Experiences of Midwifery Students/Graduates and the Baby Friendly Health Initiative 10 Steps to Successful Breastfeeding.” Women Birth 20, no. 2 (2007): 71–76. https://doi.org/10.1016/j.wombi.2007.04.003.",2007,"Australia","Hospital","BHFI overall/all steps ","Medical students- Newly graduated midwives about to commence a Graduate Midwifery Program","A review of the literature revealed many studies investigating the initiation and duration of breastfeeding and the importance of professional advice and support 3-6 but little research about how newly graduated midwives develop their practice in relation to breastfeeding support. The aim of the study was to fill this gap in the literature by investigating the factors that influence the development of the practice of breastfeeding support provided by newly graduated midwives for breastfeeding mothers.","Participants highlighted experiences such as time pressure and the established clinical practices of experienced midwives that undermined their commitment to the BFHI 10 steps. Outdated practices by senior midwives and passive resistance to the BFHI 10 steps were commonplace even in participating hospitals which are BFHI accredited. Conclusions: The clinical working environment has a major impact on the way newly graduated midwives integrate the BFHI 10 steps into their breastfeeding support practice. Commitment to the BFHI 10 steps should not be taken for granted just because a hospital achieves BFHI accreditation. Many experienced midwives are continuing with outdated practices that confuse breastfeeding mothers and newly graduated midwives alike"]
["Full Breastfeeding During the Postpartum Hospitalization and Mothersâ€™ Report Regarding Baby Friendly Practices","Breastfeeding Medicine","Rivera-Lugo, M., A. M. Parrilla-Rodriguez, R. R. Davila-Torres, C. Albizu-Garcia, and R. Rios-Motta. “Full Breastfeeding during the Postpartum Hospitalization and Mothers’ Report Regarding Baby Friendly Practices.” Breastfeeding Medicine 2, no. 1 (2007): 19–26. https://doi.org/10.1089/bfm.2006.0025.",2007,"Puerto Rico","Hospital","BHFI overall/all steps ","Postpartum women","Aim: To describe the opinion of a group of postpartum women about compliance with the Ten Steps in a hospital with the intention to be certified as a Baby Friendly Hospital.","- 43.5% of participants were practicing full breastfeeding.\n- 53% partial breastfeeding. \n- 52% of mothers perceived compliance with the Ten Steps as deficient.\n- 5.5% perceived compliance with the Ten Steps as excellent. \n- An increase in level of perceived compliance is associated with an increase in the probability of mothers breastfeeding full or exclusively. "]
["A comparison of exclusive breastfeeding in Belgian maternity facilities with and without Babyâ€\u0090friendly Hospital status","Maternal and Child Nutrition","Robert, E., I. Michaud-Letourneau, M. Dramaix-Wilmet, B. Swennen, and R. Devlieger. “A Comparison of Exclusive Breastfeeding in Belgian Maternity Facilities with and without Baby-Friendly Hospital Status.” Maternal and Child Nutrition 15, no. 4 (2019): e12845.",2018,"Belgium","Community ","BHFI overall/all steps ","Postpartum women","Aim: To compare exclusive breastfeeding(EBF) prevalence and BF practices for mothers giving birth in Baby-friendly Hospital Initiative (BFHI) and non-BFHI maternity facilities.","- A larger proportion of babies that were born in BFHI maternity facilities were exclusively breastfed in comparison to those that were born in non-BFHI hospitals. \n- In both groups the duration of EBF and the amount of children that were EBF at 5 months were similar.\n- While BFHI increased BF practices in mothers that were more likely to breastfeed the initiative didn't encourage enhanced BF practices in mothers that were more likely to not breastfeed. "]
["Impact of Hospital Policies on Breastfeeding Outcomes","Breastfeeding Medicine","Rosenberg, K. D., J. D. Stull, M. R. Adler, L. J. Kasehagen, and A. Crivelli-Kovach. “Impact of Hospital Policies on Breastfeeding Outcomes.” Breastfeed Med 3, no. 2 (2008): 110–16. https://doi.org/10.1089/bfm.2007.0039.",2008,"United States","Hospital","BHFI overall/all steps ","Hospitals","The objective of this study was to explore the association between the Ten Steps of the Baby Friendly Hospital Initiative (BFHI) of the World Health Organization (Geneva, Switzerland) and breastfeeding at 2 days and 2 weeks.","- Hospital's overall breastfeeding support scored between 49.4-98.2 out of 100.\n- Hospitals lowest compliance was with step 2 (staff training) which scored 5.3% whereas step 4 and 8 scored 93%. \n- Hospitals scores increasing can be associated with increases in percentages of breastfeeding at 2 days and at 2 weeks postpartum."]
["Assessing the Efficacy of a Breastfeeding-Friendly Quality Improvement Project in a Large Federally Qualified Health Center Network","Journal of Human Lactation","Rosen-Carole, C., E. Waltermaurer, M. Goudreault, A. Larimer, M. Pokharel-Wood, S. Rajupet, and N. Kouba. “Assessing the Efficacy of a Breastfeeding-Friendly Quality Improvement Project in a Large Federally Qualified Health Center Network.” J Hum Lact 32, no. 3 (2016): 489–97. https://doi.org/10.1177/0890334415610326.",2016,"United States","Hospital","Becoming/pre BFHI","Health workers","evaluate the effect of a Breastfeeding-Friendly Initiative (BFI) on knowledge and attitudes of providers and staff, as well as breastfeeding rates of patients within a large Federally Qualified Health Center network with no lactation consultants on staff.","- The initiation and duration of breastfeeding was found to be improved over the course of the BFI. \n- Breastfeeding duration increased with a mean of 1 month following the education module. \n- there was an improvement in provider and staff knowledge and attitudes. "]
["Are You Baby-Friendly? Knowledge  Deficit among US Maternity Staff","Journal of Human Lactation","Sadacharan, R., S. Santana, E. Sanchez, S. Matlak, X. Grossman, G. Makrigiorgos, and A. Merewood. “Are You Baby-Friendly? Knowledge Deficit among US Maternity Staff.” J Hum Lact 28, no. 3 (2012): 359–62. https://doi.org/10.1177/0890334412437039.",2012,"United States","Hospital","BHFI overall/all steps ","Health workers","To determine whether maternity staff in US hospitals could accurately describe their institution's status with regard to Baby-Friendly certification.","Results: We called 2974 hospitals, and received answers on Baby-Friendly status from 2851. According to the Baby-Friendly USA Website (http://www.babyfriendlyusa.org), 3% (75/2851) of these hospitals were Baby-Friendly. However, staff at 62% (1780/2851) stated their hospital was Baby-Friendly. Staff at 15% (424/2851) did not know what the caller meant by “Baby-Friendly hospital.” Accuracy of knowledge varied dependent on the respondent’s job title (P < .001). International Board Certified Lactation Consultants were most likely to be accurate, with 89% answering correctly. There was a strong positive correlation between the proportion of Baby-Friendly hospitals and the proportion of correct responses by state (r = 0.62, P < .001). Conclusion: Although the Baby-Friendly Hospital Initiative was established over 20 years ago, most US maternity staff responding to a telephone survey either incorrectly believed their hospital to be Baby-Friendly certified or were unaware of the meaning of “Baby-Friendly hospital.”"]
["Effectiveness of the baby-friendly community initiative in promoting exclusive breastfeeding among HIV negative and positive mothers: a randomized controlled trial in Koibatek Sub-County, Baringo, Kenya","International Breastfeeding Journal","Samburu, B. M., S. L. Young, F. M. Wekesah, M. N. Wanjohi, J. Kimiywe, P. Muriuki, P. L. Griffiths, S. T. McGarvey, N. J. Madise, and E. W. Kimani-Murage. “Effectiveness of the Baby-Friendly Community Initiative in Promoting Exclusive Breastfeeding among HIV Negative and Positive Mothers: A Randomized Controlled Trial in Koibatek Sub-County, Baringo, Kenya.” Int Breastfeed J 15, no. 1 (2020): 62. https://doi.org/10.1186/s13006-020-00299-4.",2020,"Kenya","Community ","BFCI only  ","Pregnant and postpartum women","to determine the effectiveness of BFCI in changing knowledge and attitudes towards exclusive breastfeeding (EBF) and increasing the rates among HIV negative and HIV positive women in rural Kenya.","EBF rates among HIV negative mothers were much higher in the BFCI intervention group in comparison to the control group.\n- mothers that were HIV positive in the intervention group had higher rates of EBF, However, the difference was not statistically significant.\n- There was a greater knowledge of EBF for infants exposed to HIV in the HIV negative group of the intervention arm than those in the control arm.\n- This knowledge was high in the HIV positive mothers of both the intervention and control group.\n- mothers in the intervention group had better attitudes towards EBF for HIV-exposed infants rather than the control group.\n- BFCI interventions can improve knowledge, attitudes and behaviors towards EBF among women that are HIV negative or positive."]
["A metaÂ­-ethnographic study of health care staff perceptions of the WHO/UNICEF Baby Friendly Health Initiative","Women and Birth","Schmied, V., G. Thomson, A. Byrom, E. Burns, A. Sheehan, and F. Dykes. “A Meta-Ethnographic Study of Health Care Staff Perceptions of the WHO/UNICEF Baby Friendly Health Initiative.” Women Birth 27, no. 4 (2014): 242–49. https://doi.org/10.1016/j.wombi.2014.05.005.",2014,"Multiple countries","Hospital","BHFI overall/all steps ","Academic study, meta analysis","To identify and synthesize health care staff perceptions of the WHO/UNICEF BFHI and identify facilitators and barriers for implementation","Participants were passionate about supporting breastfeeding and improving the information provided by increasing the consistency.\n- cultural and organizational constraints and obstacles to BFHI implementation were highlighted by the second theme, including issues of resource, entrenched staff practices and staff rationalization of non-compliance.\n- Optimism and enthusiasm among Participants that were able to identify a dedicated and credible leader to take charge of the BFHI change process was captured by the third theme."]
["Ten steps or climbing a mountain: A study of Australian health professionalsâ€™ perceptions of implementing the baby friendly health initiative to protect, promote and support breastfeeding","BMC  Health Services  Research","Schmied, V., K. Gribble, A. Sheehan, C. Taylor, and F. C. Dykes. “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 Serv Res 11 (2011): 208. https://doi.org/10.1186/1472-6963-11-208.",2011,"Australia","Hospital","BHFI overall/all steps ","Health workers","Examine the perceptions of BFHI held by midwives and nurses working in one Area Health Service in NSW, Australia.","Results: Three main themes were identified: ‘Belief and Commitment’; ‘Interpreting BFHI’ and ‘Climbing a Mountain’. Participants considered the BFHI implementation a high priority; an essential 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. There were, however, differing interpretations of what was required to attain BFHI accreditation with the potential that misinterpretation could hinder implementation. A model described by Greenhalgh and colleagues on adoption of innovation is drawn on to interpret the findings. \nConclusion: 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. It may be that the current processes used to disseminate and implement BFHI need to be reviewed. The findings suggest that there is a contradiction between the broad philosophical stance and best practice approach of this global strategy and the tendency for health professionals to focus on the ten steps as a set of tasks or a checklist to be accomplished. The perceived procedural approach to implementation may be contributing to lower rates of breastfeeding continuation."]
["UNICEF/WHO baby-friendly hospital initiative:does the use of bottles and paciÃ†ers in the neonatal nurseryprevent successful breastfeeding?","Eur J Pediatr ","Schubiger, G., U. Schwarz, and O. Tönz. “UNICEF/WHO Baby-Friendly Hospital Initiative: Does the Use of Bottles and Pacifiers in the Neonatal Nursery Prevent Successful Breastfeeding? Neonatal Study Group.” Eur J Pediatr 156, no. 11 (1997): 874–77. https://doi.org/10.1007/s004310050734.",1993,"Switzerland","Hospital","Steps 6 and 9","Newborns ","To investigate whether the use of bottles and pacifiers in the neonatal nursery prevent successful breastfeeding","- 46% of newborns violated the UNICEF protocol, most of the time it was due to the mother's requests to give a pacifier or supplements.\n- There was no significant differences in breastfeeding frequency and duration found. "]
["Barriers, Facilitators, and Recommendations Related to Implementing the Baby-Friendly Initiative (BFI): An Integrative Review","Journal of Human Lactation","Semenic, S., J. E. Childerhose, J. Lauziere, and D. Groleau. “Barriers, Facilitators, and Recommendations Related to Implementing the Baby-Friendly Initiative (BFI): An Integrative Review.” Special Issue: WHO/UNICEF’s Baby-Friendly Initiative. 28, no. 3 (2012): 317–34. https://doi.org/10.1177/0890334412445195.",2012,"Multiple countries","Hospital","BHFI overall/all steps ","Multiple (all the above)","Identifying and synthesizing information on the barriers, facilitators, and recommendations related to the BFI from the international, peer-reviewed literature","Priority issues to address when pursuing Baby-Friendly designation:\n-endorsements of both local administrators and governmental policy makers\n-effective leadership of the practice change process\n-health care worker training\n-the marketing influence of formula companies\n-integrating hospital and community health services. \n\nFraming the BFI as a complex, multilevel, evidence-based change process and using context-focused research implementation models to guide BFI implementation efforts may help identify effective strategies for promoting wider adoption of the BFI in health services."]
["Factors  Associated  with  Breastfeeding  Patterns  in  Western  Saudi Arabia: A Literature Review","International Journal of Child Health and Nutrition","Shahbar, A., and N. M. S. Eid. “Factors Associated with Breastfeeding Patterns in Western Saudi Arabia: A Literature Review.” International Journal of Child Health and Nutrition 8, no. 4 (2019): 145–53. https://doi.org/10.6000/1929-4247.2019.08.04.5.",2019,"Saudi Arabia","Hospital","BFHI + other interventions","Postpartum women","To review the factors that are associated with breastfeeding patterns in Western Saudi Arabia. ","The most frequent reason for mixed feeding methods was insufficient milk as well as medical and lifestyle factors.\n- women that were younger, employed and had higher-education were found to be less likely to breastfeed.\n- BFHI was found to be an effective tool in increasing the duration of breastfeeding globally.\n- in the Only paper available on BFHI in Saudi Arabia It was found that BFHI is effective However formula feeding was introduced upon discharging from hospital."]
["A  Longitudinal  Study  on  Breastfeeding  Practice  among  Women Living in Western Saudi Arab","International Journal of Child Health and Nutrition","Shahbar, A., S. Bahijri, J. Weber, and N. M. S. Eid. “A Longitudinal Study on Breastfeeding Practice among Women Living in Western Saudi Arabia.” International Journal of Child Health and Nutrition 8, no. 4 (2019): 136–44. https://doi.org/10.6000/1929-4247.2019.08.04.4.",2019,"Saudi Arabia","Hospital","BHFI overall/all steps ","Postpartum women","To assess breastfeeding practices among women in BFH and non-BFH. ","Most women that participated in the Study had initiated breastfeeding However after one month changed to mixed feedings.\n- the biggest influence on breastfeeding practices at one month was self-efficacy which was measured by the breastfeeding self-efficacy Scale.\n- infants in BFHI hospitals received breast milk as their first nutritive substance and had a higher initiation of early breastfeeding than those in non-BFHI.\n- There was no relationship between the BSES and BFHI status, most women shifted to mixed feeding one month postpartum despite the support provided such as books, internet and educational sessions."]
["Implementation of Baby Friendly Hospital Initiative in various private and public hospitals of Lahore","Pakistan Journal of Medical and Health Sciences","Shakeel, F., F. Sehar, G. Dastgir, F. Akhtar, Y. Jamil, and B. A. Jamal. “Implementation of Baby Friendly Hospital Initiative in Various Private and Public Hospitals of Lahore.” Pakistan Journal of Medical and Health Sciences 14, no. 1 (2020): 182–87.",2020,"Pakistan","Hospital","BHFI overall/all steps ","Health workers","To  determine  the  implementation  of  ten  steps  of  BFHI  in  the  randomly  selected  private  and  public hospitals/clinics of Lahore","- 60.8% of BFHI guidelines are being used and recognised in various hospitals and clinics in Lahore.\n- Maternity care practices are not being carried out completely according to the 10 steps for successful breastfeeding. "]
["Impact of a Baby-Friendly hospital on breastfeeding indicators in Shaqlawa district in Erbil governorate, Kurdistan region of Iraq","Eastern Mediterranean Health Journal","Shaker, N. Z., S. S. Hasan, and Z. A. Ismail. “Impact of a Baby-Friendly Hospital on Breastfeeding Indicators in Shaqlawa District in Erbil Governorate, Kurdistan Region of Iraq.” East Mediterr Health J 21, no. 12 (2016): 885–90. https://doi.org/10.26719/2015.21.12.885.",2015,"Iraq","Community ","BHFI overall/all steps ","Postpartum women","To assess the impact of the Baby-Friendly Hospital Initiative on WHO-defined breastfeeding indicators in Shaqlawa district in Kurdistan region of Iraq.","- early breastfeeding initiation stood at 38.1%.\n- exclusive breastfeeding was 15.4%.\ncontinued breastfeeding was 61.0%, and 39.5% at 1 and 2 years old.\n- there was a relationship present between delivery at a BFH and the early initiation of breastfeeding, however not with exclusive or continued breastfeeding."]
["The Influence of the Baby-Friendly Hospital Initiative and Maternity Care Practices on Breastfeeding Outcomes","Journal of Human Lactation","Shing, J. S., K. Y. Lok, D. Y. Fong, H. S. Fan, C. L. Chow, and M. Tarrant. “The Influence of the Baby-Friendly Hospital Initiative and Maternity Care Practices on Breastfeeding Outcomes.” J Hum Lact, 2022, 8903344221086975. https://doi.org/10.1177/08903344221086975.",2022,"Hong Kong","Hospital","BHFI overall/all steps ","Newborns and postpartum women","To examine the influence of the BFHI on breastfeeding by comparing breastfeeding outcomes in a study cohort recruited before the implementation of the BFHI and a cohort recruited after its implementation.","A higher proportion of participants from the post-implementation cohort breastfed and breastfed exclusively at all follow-up periods. Participants in the pre-BFHI cohort, on average experienced 3.10 (SD= 1.42) of the BFHI steps, whereas the participants in the post-BFHI cohort experienced 3.59 (1.09) of the BFHI steps. Half of the participants discontinued any breastfeeding by 13 weeks in the pre-BFHI cohort; more than half in the post-BFHI cohort were still breastfeeding at 6 months postpartum (p< .001). Giving only human milk in the first 48 hr of delivery and not providing pacifiers or bottles were associated with lower risk of not exclusive breastfeeding in both cohorts.\n\nDespite the improvements in breastfeeding rates after the implementation of BFHI steps, the exclusive breastfeeding rate was still very low in both cohorts."]
["The Baby-Friendly Hospital Initiative: increasing breastfeeding and decreasing infant mortality in Brazil","Rev. Bras. SaÃºde Mater. Infant., Recife","Silva, O. L. de O., M. F. Rea, S. I. Venancio, and G. dos S. Buccini. “The Baby-Friendly Hospital Initiative: Increasing Breastfeeding and Decreasing Infant Mortality in Brazil.” Revista Brasileira de Saude Materno Infantil 18, no. 3 (2018): 481. https://doi.org/10.1590/1806-93042018000300003.",2018,"Brazil","Hospital","BFHI/non-BFHI","Newborns","to estimate the population attributable fraction of preventable infant mortality rates due to changes in breastfeeding (BF) indicators attributable to the Baby Friendly Hospital Initiative (BFHI).","-  Provided by the BFHI, there was a reduction of 4.2% of late neonatal deaths due to the increase in BF prevalence in the first hour.\n- It is possible that BFHI contributed with 3.5% of all-cause deaths and 4.3% of deaths that were a result of infection by BF promotion in infants below 6 months. \n- the reduction of mortality in children between 7 and 180 days in 2008 that is potentially attributable to BFHI through promoting BF indicators that reinforce the importance of strengthening and expanding the BFHI in Brazil to ultimately enhance child survival. "]
["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","Silva, O. L. O., M. F. Rea, F. M. Sarti, and G. Buccini. “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, 1–11. https://doi.org/10.1017/s1368980020001871.",2020,"Brazil","Hospital","BHFI overall/all steps ","Postpartum women","To analyse the cost-effectiveness of Baby-Friendly Hospital Initiative(BFHI) in promoting breast-feeding during the first hour of life (BFFHL) and reducing late neonatal mortality.","- Cost-effective analysis revealed that BFHI was extremely cost-effective in raising BFFHL by 32% at lower cost when compared to non-BFHI. \n- BFHI was cost-effective in the reduction of late neonatal mortality rate by 13% from all causes and by 13.1% of infant mortalities that were a result of infections. "]
["Prevalence and factors associated with maternal breastfeeding in the first hour of life in full-term live births in southwest Bahia, Brazil, 2017","Epidemiol. Serv. Saude","Sousa, P. K. S., T. G. Novaes, Eids Magalhães, A. T. Gomes, V. M. Bezerra, M. Pereira Netto, and D. D. S. Rocha. “Prevalence and Factors Associated with Maternal Breastfeeding in the First Hour of Life in Full-Term Live Births in Southwest Bahia, Brazil, 2017.” Epidemiol Serv Saude 29, no. 2 (2020): e2018384. https://doi.org/10.5123/s1679-49742020000200016.",2020,"Brazil","Hospital & Community","Step 4","Newborns and postpartum women","To analyse prevalence and factors associated with maternal breastfeeding in the first hour of life (MBFFHL) in full-term live births in VitÃ³ria da Conquista, BA, Brazil. ","- MBFFHL stood at 49.5% prevalence, this outcome was associated with maternal education longer than 12 years, prenatal guidance on the holding and positioning of children, the infant being given to the mother soon after being delivered and rooming-in as well as delivery at baby-friendly hospital. \n- MBFFHL can be associated with maternal factors, hospital care and prenatal care. "]
["Evaluation of breastfeeding promotion in Baby-Friendly Hospitals","Rev Paul Pediatr ","Souza, M. F. L., P. N. Ortiz, P. L. Soares, T. O. Vieira, G. O. Vieira, and L. R. Silva. “Evaluation of Breastfeeding Promotion in Baby-Friendly Hospitals.” Revista Paulista de Pediatria 29, no. 4 (2011): 502–8. https://doi.org/10.1590/S0103-05822011000400006.",2011,"Brazil","Hospital","BHFI overall/all steps ","Postpartum women","To  evaluate  the  compliance  to  steps  4  to 10 of the Ten Steps Program to Successful Breastfeeding recommended  by  the  Baby-Friendly  Hospital  Initiative  (BFHI),  created  by  World  Health  Organization (WHO).","- compliance with step 1, 5 and 10 was unsatisfactory. \n- Compliance with step 6, 7 and 9 was adequate. "]
["Babyâ€\u0090Friendly Hospital designation has a sustained impact on continued breastfeeding","Maternal & Child Nutrition","Spaeth, A., E. Zemp, S. Merten, and J. Dratva. “Baby-Friendly Hospital Designation Has a Sustained Impact on Continued Breastfeeding.” Matern Child Nutr 14, no. 1 (2018). https://doi.org/10.1111/mcn.12497.",2017,"Switzerland","Hospital & Community","BHFI overall/all steps ","Newborns and postpartum women","To investigate the association of BFH designation (current, former, and never) and compliance with Baby Friendly (BF) practices on breastfeeding in Switzerland.","- There was an average duration of exclusive breastfeeding of 13.1 weeks and any breastfeeding at 32.7 weeks were the longest for babies that were delivered in hospitals that were accredited BFHs. \n- Continued breastfeeding was found to be significantly longer when babies were delivered in BFHs or Hospitals that were formerly BFHs. \n"]
["A systematic review of education and evidence-based practice interventions with health professionals and breastfeeding counsellors on duration of breast feeding","Midwifery","Spiby, H., F. McCormick, L. Wallace, M. J. Renfrew, L. D’Souza, and L. Dyson. “A Systematic Review of Education and Evidence-Based Practice Interventions with Health Professionals and Breast Feeding Counsellors on Duration of Breast Feeding.” Midwifery 25, no. 1 (2009): 50–61. https://doi.org/10.1016/j.midw.2007.01.006.",2009," UK, USA, Canada, and four European countries","Hospital & Community","BFHI + other education and evidence-based practice ","Key Informants: Health professionals and lay breast feeding educators/counsellors ","To examine the effects of training, education and practice change interventions with health professionals and lay breast feeding educator/ counsellors on duration of breast feeding. (This was part of a series of reviews of interventions that affect duration of breast feeding).","All were before and after studies that included the education of health professionals; no studies were identified that related to breast feeding counsellors.  In six of the studies, the participants were working with mothers and babies in hospitals (three in the UK, two in Italy and one in France); in three studies, the participants were working in community settings (Canada, Spain and the USA).Two UK studies and two non-UK studies (Spain and USA) involved mothers living in disadvantaged areas. Most interventions aimed to increase knowledge and change professional practice in support of breast feeding.\n\nRe the 1 relevant included study: The  proportion  of  women  continuing  breastfeeding was increased after the introduction ofthe  18-hour  UNICEF  training  in  eight  Italian hospitals, albeit in the context of a very low baseline rate of breastfeeding."]
["The Role of the Nurse-Physician Leadership Dyad in Implementing the Baby-Friendly Hospital Initiative","Nursing for Womenâ€™s Health","St Fleur, R., and J. McKeever. “The Role of the Nurse-Physician Leadership Dyad in Implementing the Baby-Friendly Hospital Initiative.” Nurs Womens Health 18, no. 3 (2014): 231–35. https://doi.org/10.1111/1751-486x.12124.",2014,"United States","Hospital","BHFI overall/all steps ","Health workers","To investigate The Role of the Nurse-Physician Leadership Dyad in Implementing the Baby-Friendly Hospital Initiative","The leadership dyad model is an effective strategy in order to facilitate change in the current Health care environment\n- the dyad model was uniquely adapted at JSUMC and used to achieve designation, as the BFHI requires an interdisciplinary approach.\n- the dyad model can improve the quality improvement process through the creation of a specific Role for physician involvement that encourages a motivation for change."]
["OBSERVANCE OF WHO TEN STEPS TOWARDS SUCCESSFUL BREASTFEEDING; A SURVEY FROM POSTPARTUM MOTHERS","J Ayub Med Coll Abbottabad ","Sumaira, Masood, Rahman Mahmood ur, Mahmood Humaira, Faisal Tayyaba, Maroof Saira, and A. M. Qureshi. “Observance of WHO Ten Steps towards Successful Breastfeeding; a Survey from Postpartum Mothers.” Journal of Ayub Medical College 28, no. 1 (2016): 84–88.",2016,"Pakistan","Hospital","BHFI overall/all steps ","Postpartum women","To determine the frequency  of  mothers practicing  successful  breastfeeding  according  to the WHO  ten  steps at tertiary  care  hospital.","- 23.7% of mothers knew 7 or more steps.\n- 67.6% received support from healthcare staff for breastfeeding during their stay at the hospital.\n- 12.8% of mothers started breastfeeding within one hour of delivery.\n- 71% had started to combine breastfeeding and the use of formula.\n- 85.8% fed their child on demand.\n- 97.3% did not give dummies to their baby. \n- There was statistically significant differences observed as housewife mothers were found did not give top feed and mothers who were multiparous began breastfeeding within an hour of delivery.  "]
["Night Rooming-in: Who Decides?A n Example of Staff Influence on Motherâ€™s Attitude","Birth","Svensson, K., A. S. Matthiesen, and A. M. Widstrom. “Night Rooming-in: Who Decides? An Example of Staff Influence on Mother’s Attitude.” Birth 32, no. 2 (2005): 99–106. https://doi.org/10.1111/j.0730-7659.2005.00352.x.",2005,"UK","Hospital","Step 7","Postpartum women","The purpose of this study was to investigate, first,  whether  or  not  mothers  at  our  hospital roomed-in with their babies at night (night rooming-in), second, the attitudes of mothers toward night  rooming-in  and  toward  closeness  to  the baby, and third, how the mothers perceived hospital staff attitudes toward night rooming-in and how this affected mothers' choice whether or not to room-in at night.","58 of mothers chose rooming-in, 53 chose not to. In both groups mothers perceived that the hospital staff preferred the option they chose."]
["A descriptive study of breastfeeding practices and policies in Missouri Hospitals","Journal of Human Lactation","Syler, G. P., P. Sarvela, K. Welshimer, and S. L. Anderson. “A Descriptive Study of Breastfeeding Practices and Policies in Missouri Hospitals.” J Hum Lact 13, no. 2 (1997): 103–7. https://doi.org/10.1177/089033449701300209.",1993,"United States","Hospital","BHFI overall/all steps ","Hospital management","To measure compliance with all 10 steps of BFHI in Missouri","None of the Missouri hospitals that offer maternity services fully practiced BFHI. Implementation scores ranged from 41-686%, mean score: 69% (SD=12). \nLeast support (28%) was for step 1, greatest support (93%) was for step 3, inconsistencies in implementation of other steps were common."]
["Association of hospital and community factors on theattainment of Babyâ€\u0090Friendly designation: A breastfeeding health promotion","Maternal and child nutrition","Tafili, Aurora, Nazik M. A. Zakari, Hanadi Y. Hamadi, and Aaron Spaulding. “Association of Hospital and Community Factors on the Attainment of Baby‐Friendly Designation: A Breastfeeding Health Promotion.” Maternal & Child Nutrition 18, no. 3 (2022): 1–9. https://doi.org/10.1111/mcn.13388.",2022,"United States","Hospital","BHFI overall/all steps ","Hospitals ","to determine which hospital characteristics and community factors are associated with hospitals' attainment of Baby Friendly designation. ","Our results show that Baby Friendly hospitals are more likely to be government nonfederal hospitals, inthe Midwest or South regions, serve communities with higher birth totals, and reside in competitive markets. "]
["Doestelephonelactationcounsellingimprovebreastfeedingpractices?: A randomised controlled trial","International Journal of Nursing Studies","Tahir, N. M., and N. Al-Sadat. “Does Telephone Lactation Counselling Improve Breastfeeding Practices? A Randomised Controlled Trial.” Int J Nurs Stud 50, no. 1 (2013): 16–25. https://doi.org/10.1016/j.ijnurstu.2012.09.006.",2013,"Malaysia","Hospital","Step 5","Postpartum women","Aim: To study the effectiveness of telephone lactation counselling on breastfeeding practices. Using a  single blinded, randomised controlled trial (RCT). Setting: Maternity wards in a public hospital in Kuala Lumpur, Malaysia.","At 1 month, a higher percentage of mothers in the intervention group practiced exclusive breastfeeding, compared to the control group (84.3% vs. 74.7%). At 4 and 6 months postpartum, similar percentages of mothers from the two groups practiced exclusive breastfeeding. Mothers in the control group stopped BF completely at 1, 4 or 6 months in slightly higher numbers than treatment group. "]
["Knowledge of, and attitudes to giving expressed breastmilk to infants in rural coastal Kenya; focus group discussions of first time mothers and their advisers","International Breastfeeding Journal","Talbert, A. W., B. Tsofa, E. Mumbo, J. A. Berkley, and M. Mwangome. “Knowledge of, and Attitudes to Giving Expressed Breastmilk to Infants in Rural Coastal Kenya; Focus Group Discussions of First Time Mothers and Their Advisers.” Int Breastfeed J 13 (2018): 16. https://doi.org/10.1186/s13006-018-0158-9.",2018,"Kenya","Community ","Step 4, specifically expressed milk consumption","Postpartum women, first-time mothers","Exploring the knowledge of, and attitudes to, the practice of giving expressed breastmilk.","Feeding expressed breastmilk to infants is a new concept in the rural Kenyan context where the research was conducted. Promotion of, and training in this practice would help mothers to maintain their milk supply when away from their babies and benefit the infants of working and schoolgirl mothers."]
["Postpartum womenâ€™s perception of antenatal breastfeeding education: a descriptive survey","International Breastfeeding Journal  ","Tan, M. L., S. C. Foong, J. J. Ho, W. C. Foong, R. Mohd, and Z. Harun. “Postpartum Women’s Perception of Antenatal Breastfeeding Education: A Descriptive Survey.” Int Breastfeed J 15, no. 1 (2020): 85. https://doi.org/10.1186/s13006-020-00328-2.",2020,"Malaysia","Pre-natal outpatient support ","Step 5, Ante-natal breastfeeding education ","Postpartum women","To determine how women perceived their ANBE experience in the first 8 weeks postpartum including what was useful and what they would like to have been included, sources of ANBE and infant feeding practices at the time of survey.","Almost all women found antenatal breastfeeding education useful. However, there were areas both in the delivery (e.g. too short) and the content (e.g. nothing new) that were described as not useful; and areas they would like more coverage (e.g. milk expression, storage and overcoming low milk supply). The exclusive breastfeeding prevalence at the time of survey was 61%."]
["Impact of Baby-Friendly Hospital Practices on Breastfeeding in Hong Kong","Birth: Issues in Perinatal Care","Tarrant, M., K. M. Wu, D. Y. Fong, I. L. Lee, E. M. Wong, A. Sham, C. Lam, and J. E. Dodgson. “Impact of Baby-Friendly Hospital Practices on Breastfeeding in Hong Kong.” Birth 38, no. 3 (2011): 238–45. https://doi.org/10.1111/j.1523-536X.2011.00483.x.",2011,"Hong Kong","Hospital & Community","BHFI overall/all steps ","Newborns and postpartum women","To examine exposure to Baby-Friendly practices among mothers delivering in public hospitals in Hong Kong and to assess the impact of individual and cumulative Baby-Friendly hospital practices on breastfeeding duration","Only 46.6 percent of women breastfed for more than 8 weeks, and only 4.8 percent of mothers experienced all six Baby-Friendly practices. After controlling for all other Baby-Friendly practices and possible con-founding variables, exclusive breastfeeding while in hospital was protective against early breast feeding cessation (OR: 0.61; 95% CI: 0.42-0.88). Compared with mothers who experienced all six Baby-Friendly practices, those who experienced one or fewer Baby-Friendly practices were almost three times more likely to discontinue breastfeeding (OR: 3.13; 95% CI:1.41-6.95)."]
["Effect on Baby-Friendly Hospital Steps When Hospitals Implement a Policy to Pay for Infant Formula","Journal of Human Lactation","Tarrant, M., K. Y. Lok, D. Y. Fong, K. M. Wu, I. L. Lee, A. Sham, C. Lam, et al. “Effect on Baby-Friendly Hospital Steps When Hospitals Implement a Policy to Pay for Infant Formula.” J Hum Lact 32, no. 2 (2016): 238–49. https://doi.org/10.1177/0890334415599399.",2016,"Hong Kong","Hospital","BHFI overall/all steps ","Newborns and postpartum women","To investigate the effect of hospitals implementing a policy of paying for infant formula on new mothers' exposure to Baby-Friendly steps and examine the effect of exposure to Baby-Friendly steps on breastfeeding rates.","After hospitals began paying for infant formula, new mothers were more likely to experience 4 out of 6 BFHI steps. Breastfeeding initiation within the first hour increased from 28.7% to 45%, and in-hospital exclusive breastfeeding rates increased from 17.9% to 41.4%. \nThe proportion of mothers who experienced all 6 BFHI steps increased from 4.8% to 20.5%. The risk of weaning was progressively higher among participants experiencing fewer BFHI steps. Each additional step experienced by new mothers decreased the risk of breastfeeding cessation by 8%."]
["Staff Perceptions and Experiences of Implementing the Baby Friendly Initiative in Neonatal Intensive Care Units in Australia","Journal of Obstetric, Gynecologic & Neonatal Nursing","Taylor, C., K. Gribble, A. Sheehan, V. Schmied, and F. Dykes. “Staff Perceptions and Experiences of Implementing the Baby Friendly Initiative in Neonatal Intensive Care Units in Australia.” J Obstet Gynecol Neonatal Nurs 40, no. 1 (2011): 25–34. https://doi.org/10.1111/j.1552-6909.2010.01204.x.",2010,"Australia","Hospital Neonatal Intensive Care Unit","BFHI in Neonatal Intensive Care Unit (NICU)","NICU health workers","To explore the perceptions, understandings, and experiences of maternity service staff toward the World Health Organization/United Nations Children's Fund (WHO/UNICEF) Baby Friendly Hospital Initiative (BFHI) and its implementation in the Neonatal Intensive Care Unit (NICU).","Findings illuminate some of the complexities of implementing the BFHI in NICUs. Major themes:\n-differences in NICUs relative to maternity units\n-separate worlds of mother and infant\n-hard work involved in implementing the BFHI\n- positive attitude that BFHI can be achieved\n-misconceptions re nature of the BFHI as it applied to NICUs \n-factors hindering and supporting BFHI implementation "]
["Implementing the Ten Steps for Successful Breastfeeding in Hospitals Serving Low-Wealth Patients","American Journal of Public Health","Taylor, E. C., N. C. Nickel, and M. H. Labbok. “Implementing the Ten Steps for Successful Breastfeeding in Hospitals Serving Low-Wealth Patients.” Am J Public Health 102, no. 12 (2012): 2262–68. https://doi.org/10.2105/ajph.2012.300769.",2012,"United States","Hospital","BHFI overall/all steps ","Health workers, postpartum women, hospital management, physicians, nurse-practitioners, nurses and international board certified lactation consultants","The Ten Steps to Successful Breastfeeding is a proven approach to support breastfeeding in maternity settings; however, scant literature exists on the relative impact and interpretation of each step on breastfeeding. We assessed the Ten Steps and their relationship with in-hospital breastfeeding rates at facilities serving low-wealth populations and explored the outcomes to identify step-specific actions.","Self-appraisal may be less valid when not all elements of the criteria for evaluating Step implementation may be fully understood. Nonetheless, the indication that breastfeeding rates may be better mirrored by a defined subset of steps may provide some constructive insight toward prioritizing implementation activities and simplifying assessment."]
["Implementing the WHO/UNICEF Baby Friendly Initiative in the community: a â€˜hearts and mindsâ€™ approach","Midwifery","Thomson, G., A. Bilson, and F. Dykes. “Implementing the WHO/UNICEF Baby Friendly Initiative in the Community: A ‘hearts and Minds’ Approach.” Midwifery 28, no. 2 (2012): 258–64. https://doi.org/10.1016/j.midw.2011.03.003.",2012,"UK","Primary care trusts (PCTs). PCTs are responsible for delivering primary care, such as general practitioners (family doctors) and health visitor care.","Becoming BFHI ('7 Point Community Plan'-UNICEF UK adaptation)","Key Informants: Public health + local council employees, midwifery/maternity services staff, health visitors and members of the Breastfeeding Network (BfN) a UK-based voluntary organisation. ","Describe a 'hearts and minds' approach to community Baby Friendly Initiative implementation developed from the views of multidisciplinary professionals. The aim of this study was to explore the approach used to implement the community BFI award from the perspective of the professionals involved.","Thematic networks analysis generated a global theme of a 'hearts and minds approach' to BFI implementation, which embodies emotional and rational engagement. The three underpinning organising themes 'credible leadership', 'engagement of key partners' and 'changing attitudes and practice' reflect the context, processes and outcomes of a 'hearts and minds' approach."]
["Womenâ€™s Sense of Coherence related to their infant feeding experiences","Maternal and Child Nutrition","Thomson, G., and F. Dykes. “Women’s Sense of Coherence Related to Their Infant Feeding Experiences.” Matern Child Nutr 7, no. 2 (2011): 160–74. https://doi.org/10.1111/j.1740-8709.2010.00251.x.",2010,"UK","Community ","BFCI only  ","Postpartum women","As part of an evaluation study of the implementation of the UNICEF UK Baby Friendly Initiative(BFI) Community Award within two primary (community-based) care trusts in North West England, 15 women took part in an in-depth interview to explore their experiences, opinions and perceptions of infant feeding. In this paper, we  have  provided  a  theoretical  interpretation  of  these  women's  experiences  by  drawing  upon Aaron Antonovsky's Sense of Coherence(SOC) theory. The SOC is a global orientation to how people are able to cope with stressors and maintain a sense of well-being.","Women's experiences of infant feeding are influenced by the extent to which they are 'comprehensible', 'manageable' and 'meaningful'. Application of this knowledge and understanding can support practitioners in addressing the wider socio-cultural pressures which  impact  upon  women's  ways  of  negotiating infant feeding within a specific cultural context. Application  of  this  knowledge  by  health  care  staff  when implementing the BFI will help and support women to negotiate infant feeding in ways that integrate with their personal situation and circumstances."]
["The Effect of Health Worker Training on Early Initiation of Breastfeeding in South Sudan: A Hospital-based before and after Study","International Journal of Environmental Research and Public Health","Tongun, J. B., J. K. Tumwine, G. Ndeezi, M. B. Sebit, D. Mukunya, J. Nankunda, and T. Tylleskar. “The Effect of Health Worker Training on Early Initiation of Breastfeeding in South Sudan: A Hospital-Based before and after Study.” Int J Environ Res Public Health 16, no. 20 (2019). https://doi.org/10.3390/ijerph16203917.",2019,"South Sudan","Hospital","BFHI staff training","Newborns and postpartum women","We assessed the effect of a Baby-Friendly Hospital Initiative training on early initiation of breastfeeding at Juba Teaching Hospital in South Sudan. ","The prevalence of early initiation of breastfeeding increased from 48% (388/806) before to 91% (732/806) after training. Similarly, early initiation of breastfeeding increased from 3% (3/97) before to 60% (12/20) after training among women who delivered by caesarean section. About 8% (67/806) of mothers discarded colostrum before compared to 3% (24/806) after training. Further, 17% (134/806)of mothers used pre-lacteal feeds before compared to only 2% (15/806) after training.  Regardless of the mode of birth, the intervention was effective in increasing early initiation of breastfeeding[adjusted prevalence ratio (APR) 1.69, 95% confidence interval CI (1.57-1.82)]. These findings suggest an urgent need to roll out the training to other hospitals in South Sudan. This will result in improved breastfeeding practices, maternal, and infant health."]
["Comparison of infant-feeding practices in two health subdistricts with different baby-friendly status in Mpumalanga province","South African Journal of Clinical Nutrition","Van Der Merwe, M., L. Du Plessis, and H. Jooste. “Comparison of Infant Feeding Practices in Two Health Sub-Districts with Different Baby Friendly Status in Mpumalanga Province.” Annals of Nutrition and Metabolism 63 (2013): 532. https://doi.org/10.1159/000354245.",2013,"South Africa","Hospital","BHFI overall/all steps ","Newborns and postpartum women","The objective of the study was to compare the infant-feeding practices of two sub districts with different baby-friendly status in Mpumalanga province, South Africa.","There was a significantly higher early initiation of breastfeeding (57% vs. 43%), exclusive breastfeeding rates (60% vs 48%), and a lower exclusive replacement feeding rate (18% vs. 33%) in Emalahleni sub district, where all the public sector maternity facilities are accredited as being baby friendly, compared to that in Mbombela sub district, where none of the public sector maternity facilities are baby friendly. The mixed feeding rate (19% vs. 15%) and the mean age of the introduction of complementary foods (50 days versus 35 days) did not differ significantly between the two sub districts."]
["Evaluating Implementation of a Baby Friendly Hospital Initiative","MCN Am J Matern Child Nurs","VanDevanter, Nancy, Susan Gennaro, Wendy Budin, Helene Calalang-Javiera, and Nguyen Minh. “EVALUATING IMPLEMENTATION OF A Baby Friendly HOSPITAL INITIATIVE.” Mcn-the American Journal of Maternal-Child Nursing 39, no. 4 (2014): 231–37. https://doi.org/10.1097/nmc.0000000000000046.",2014,"United States","Hospital","BHFI overall/all steps ","Health workers","To evaluate the implementation of the BFHI in a large urban hospital in New York city that serves primarily poor, minority women ","- 9/10 BFHI steps had been fully or partially implemented. 1 had not (offering support groups after discharge) \n- 7 steps had been fully implemented (Step 1, 2 3, 4, 7, 8,9). \n- Although written policies were developed for 2 of the steps (Step 4, 6) they were not consistenly followed.  "]
["The Baby-Friendly Hospital Initiative and breastfeeding in a neonatal unit","Rev SaÃºde PÃºblica","Vannuchi, M. T. O., C. A. Monteiro, M. F. Rea, S. M. de Andrade, and T. Matsuo. “The Baby-Friendly Hospital Initiative and Breastfeeding in a Neonatal Unit.” Revista de Saude Publica 38, no. 3 (2004): 422–28. https://doi.org/10.1590/s0034-89102004000300013.",2004,"Brazil","Hospital","BHFI overall/all steps ","Newborns and postpartum women","The study was conducted after the implementation of the BFHI program, and included an comparison with records from a similar-sized group of mother baby pairs from several years previously, pre-BFHI, whose records were already present in the healthcare facility. The effects of BFHI on neonatal EBF and BF was the focus. ","Increase of babies being EBF: from 1.9% in 1994 to 41.7% in 1998. Milk bank used extensively in 1998 (compared to no uptake of milk bank in 1994). Increasing the rate of BF during ICU admission and outpatient follow up periods is also a means of ensuring the long-term benefits brought by this breast-feeding in terms of the immunological, emotional, nutritional, and neurological development of these children."]
["The Baby-Friendly Journey in a US Public Hospital","Journal of Perinatal Neonatal Nursing","Vasquez, M. J., and O. R. Berg. “The Baby-Friendly Journey in a US Public Hospital.” J Perinat Neonatal Nurs 26, no. 1 (2012): 37–46. https://doi.org/10.1097/JPN.0b013e3182107179.",2012,"United States","Hospital","Becoming/pre BFHI","Health facility level: birth centres","Describing the process of implementing The Baby-Friendly Hospital Initiative quality improvement program, achieving certification and subsequent increase in breast-feeding rates.","In 2007, the SFGH was finally certified as a Baby-Friendly Hospital; 5 most challenging quality initiatives were staff education, prenatal education, rooming in efforts, skin-to-skin contact, and ending the routine use of artificial nipples (pacifiers and bottles). "]
["The Baby-Friendly Hospital Initiative shows positive effects on breastfeeding indicators in Brazil","Journal of Epidemiology and Community Health","Venancio, Sonia Isoyama, Silvia Regina Dias Medici Saldiva, Maria Mercedes Loureiro Escuder, and Elsa Regina Justo Giugliani. “The Baby-Friendly Hospital Initiative Shows Positive Effects on Breastfeeding Indicators in Brazil.” Journal of Epidemiology and Community Health 66, no. 10 (2012): 914–18. https://doi.org/10.1136/jech-2011-200332.",2012,"Brazil","Hospital & Community","BHFI overall/all steps ","Newborns ","Assess the influence of the BFHI on breastfeeding indicators in Brazil, using data from the 2nd Survey of Breastfeeding Prevalence, conducted in 2008","Infants born in BFHs were 9% more likely to be breast fed in the first hour of life and 6% more likely to be breast fed on the first day at home. Exclusive breast feeding was 13%, 8% and 6% more likely in infants under the ages of 2, 3 and 6 months, respectively, born in BFHs. Birth in a BFH also correlated with significant less pacifier use."]
["Feeding newborns after hospital discharge from a Baby-Friendly Health Care Institution","Acta Paul Enferm","Vivancos, R. B. Z., A. M. Leite, M. C. C. Furtado, F. S. N. de Góes, V. J. Haas, and C. G. S. Scochi. “Feeding Newborns after Hospital Discharge from a Baby-Friendly Health Care Institution.” Acta Paulista de Enfermagem 21, no. 3 (2008): 439–43.",2008,"Brazil","Hospital","BHFI overall/all steps ","Newborns and postpartum women","To characterize the way of  feeding newborns (NB)during their hospital stay and after hospital discharge from a Baby-Friendly Health Care institution, using the indicators proposed by the WHO.","The proportion of newborns BF after hospital discharge was higher in the group that had early skin-to-skin contact (88.9%) when compared to babies who did not (80.6%). Also, the proportion of  newborns BF after hospital discharge was higher in the group that had early suction while still in the delivery room (92.3%) when compared to the group that did not (80.6%)."]
["Educational videos for practitioners attending Baby Friendly Hospital Initiative workshops supporting breastfeeding positioning, attachment and hand expression skills: Effects on knowledge and confidence","Nurse education in practice","Wallace, L. M., Y. Ma, L. Q. Qiu, and O. M. Dunn. “Educational Videos for Practitioners Attending Baby Friendly Hospital Initiative Workshops Supporting Breastfeeding Positioning, Attachment and Hand Expression Skills: Effects on Knowledge and Confidence.” Nurse Educ Pract 31 (2018): 7–13. https://doi.org/10.1016/j.nepr.2018.04.005.",2018,"UK and China","Hospital","Staff training for BFHI","Health workers","Test the impact (and most suitable order) of a video with a clinical demonstration to supplement health practitioners BFHI training to support mothers in the essential skills of supporting positioning and attachment, and hand expression. ","In all 3 phases there were statistically significant improvements in confidence in practice in both skills. Viewing short videos increased knowledge, particularly about teaching hand expression, and confidence in both skills. Barriers include: In the community, healthcare practitioners do not often see successful breastfeeding, still less successful hand ex-pression, as they are more often called upon when there are feeding problems. The researchers concluded that practitioners may over estimate their knowledge and without objective assessment, they may apply incorrect knowledge in their practice."]
["An Examination of Maternity Staff Attitudes Towards Implementing Baby Friendly Health Initiative (BFHI) Accreditation in Australia","Maternal Child Health Jourbal ","Walsh, A. D., J. Pincombe, and A. Henderson. “An Examination of Maternity Staff Attitudes towards Implementing Baby Friendly Health Initiative (BFHI) Accreditation in Australia.” Matern Child Health J 15, no. 5 (2011): 597–609. https://doi.org/10.1007/s10995-010-0628-1.",2011,"Australia","Hospital","Becoming/pre BFHI","Health workers","To examine the factors perceived to promote or hinder BFHI accreditation.","Staff's understanding and  personal  views  are  often  discordant  with  BFHI  aims. Perceived  difficulties  include: \n-Accreditation  process\n-Hospital dynamics\n-Ten Steps implementation \n-A bottle   feeding   culture\n-Maternal   employment   that impact  upon  continued  breastfeeding"]
["The ten steps to successful breastfeeding in Australian hospitals ","Breastfeeding Review","Walsh, A. D., J. Pincombe, and G. E. Stamp. “The Ten Steps to Successful Breastfeeding in Australian Hospitals.” Breastfeed Rev 14, no. 1 (2006): 25–31.",2006,"Australia","Hospital","BHFI overall/all steps ","Health workers","Assess the degree of implementation of 10 steps in Australian hospitals","-High rates of implementation of steps1a, 3, 4, 5, 6, 8 and 9.\n-Mean rate of women breastfeeding at discharge was 88% (out of 283 responses).\n-Step 1b, 2, 7 and 10 should be targeted for improvement."]
["A Critical Review of the Impact of  Continuing Breastfeeding Education  Provided to Nurses and Midwives","Journal of Human Lactation","Ward, K. N., and J. P. Byrne. “A Critical Review of the Impact of Continuing Breastfeeding Education Provided to Nurses and Midwives.” J Hum Lact 27, no. 4 (2011): 381–93. https://doi.org/10.1177/0890334411411052.",2011,"9 different countries","Hospital & Community","Becoming BFHI and BFHI settings ","Health workers","The aim of this review was to analyze the effects of educational interventions on breastfeeding aimed at already practicing health professionals, particularly nurses and midwives.","-Increased knowledge after intervention was the single greatest point of unity in the studies reviewed. Eight studies directly measured knowledge, with all finding a statistically significant increase, and 6 studies measured changes in attitude, with all but 1 study finding that breastfeeding attitudes improved after intervention. \n-Improvement in attitude was found regardless of whether the nurses and midwives were working in an environment where management supported and implemented policies and procedures based on best evidence-based breastfeeding practice.\n-4 out of 5 studies examining the timing of initiation of breastfeeding found increases in the number of babies who were breastfed within 1 hour of birth.\n-3 out of 4 studies reported improved 24h rooming-in practice.\n-All continuing education programs having varying degrees of success in reducing supplementation.\n"]
["Improving Exclusive Breastfeeding in an Urban Academic Hospital","PEDIATRICS","Ward, Laura P., and Susan Williamson. “Improving Exclusive Breastfeeding in an Urban Academic Hospital.” Pediatrics 139, no. 2 (2017): 78–78. https://doi.org/10.1542/peds.2016-0344.",2017,"United States","Hospital","Becoming/pre BFHI","Health workers","Description of 'becoming BFHI trajectory': formal improvement science methods were used, including the development of a key driver diagram and plan, study, act cycles. Improvement activities followed the Ten Steps to Successful Breastfeeding.","-Significant improvement in the median adherence to 2 process measures, rooming in and skin-to-skin after delivery. \n-Subsequently, the proportion of infants exclusively breastfed at hospital discharge in our facility increased from 37% to 59%. \n-Demonstrated  increase in sustained breastfeeding in a subset of patients at a postpartum follow-up visit. -Improvements led to Baby-Friendly designation at our facility."]
["Perspectives of Hospital-Based Nurses on Breastfeeding Initiation Best Practices","Journal of Gynecology, Obstetrics and Neonatal Nursing","Weddig, J., S. S. Baker, and G. Auld. “Perspectives of Hospital-Based Nurses on Breastfeeding Initiation Best Practices.” J Obstet Gynecol Neonatal Nurs 40, no. 2 (2011): 166–78. https://doi.org/10.1111/j.1552-6909.2011.01232.x.",2011,"United States","Hospital","Step 4, BF initiation","Health workers","To assess the variation in breastfeeding knowledge and practices of registered nurses in hospital women and family-care units and the informal and formal hospital policies related to the initiation and support of breastfeeding.","Majority of nurses self-reported being knowledgeable of evidence-based best practices related to breast-feeding initiation. \nIn non-BF/BF(intent) settings, nurses' knowledge + hospital policies was often not in accordance with current best practices in breastfeeding initiation. "]
["ANALYSIS OF THE OUTCOMES AT BABY-FRIENDLY HOSPITALS: APPRAISAL IN TAIWAN","Kaohsiung Journal of Medical Science","Weng, D. R., ChunSen Hsu, MeeiLing Gau, ChaoHuei Chen, and ChungYi Li. “Analysis of the Outcomes at Baby-Friendly Hospitals: Appraisal in Taiwan.” Kaohsiung Journal of Medical Sciences 19, no. 1 (2003): 19–28. https://doi.org/10.1016/S1607-551X(09)70443-7.",2003,"Taiwan","Hospital","Becoming/pre BFHI","Hospitals  and postpartum women","This study examined the effect of the Baby-Friendly Hospital Initiative (BFHI) on the breastfeeding rate in Taiwan and analyzed factors related to BFHI qualification. The assessments included 56 hospitals enlisted for appraisal and 7,563 mothers in the maternity wards of these hospitals. ","Among the 56 hospitals appraised, 38 (67.9%) passed appraisal. Geographically, 88.5% (23/38) of hospitals are located in northern Taiwan, and only one hospital is situated in eastern Taiwan. All 13 medical centers enlisted for appraisal were qualified as BFHI. Only one private clinic passed the appraisal."]
["The New Hampshire Ten Steps to Successful Breastfeeding Collaborative: A Statewide QI Initiative","Hospital Pediatrics","Whalen, B. L., J. Kelly, and A. V. Holmes. “The New Hampshire Ten Steps to Successful Breastfeeding Collaborative: A Statewide QI Initiative.” Hosp Pediatr 5, no. 6 (2015): 315–23. https://doi.org/10.1542/hpeds.2014-0104.",2015,"United States","Hospital","Becoming/pre BFHI","Health workers and hospital management","To assess Ten Steps achievement among hospitals that participated in BFHI workshops","-Staff education (step 2) achievement went from 1 to 6 hospitals. -No statistically significant changes in number of hospitals implementing step 6 (breast milk only) and step 9 (no artificial nipples).\n-Intensive collaborative hospitals achieved an average of 1.5 new steps, whereas nonâ€“Baby Friendly hospitals lost 0.7 steps. \n-In-hospital breastfeeding rates increased in intensive collaborative hospitals and were significantly higher than those in nonâ€“Baby Friendly hospitals (any breastfeeding, 89% vs 73%, P = .03; exclusive breastfeeding, 84% vs 61%, P< .001)"]
["The struggle for inter-professional teamwork and collaboration in maternity care: Austrian health professionalsâ€™ perspectives on the implementation of the Baby-Friendly Hospital Initiative","BMC Health Services Research","Wieczorek, Christina C., Benjamin Marent, Thomas E. Dorner, and Wolfgang Duer. “The Struggle for Inter-Professional Teamwork and Collaboration in Maternity Care: Austrian Health Professionals’ Perspectives on the Implementation of the Baby-Friendly Hospital Initiative.” BMC Health Services Research 16 (2016). https://doi.org/10.1186/s12913-016-1336-3.",2016,"Austria","Hospital","BHFI overall/all steps ","Health workers and hospital management","Study investigates the ways in which different healthcare professionals struggle to work together to successfully integrate the BFHI into practice.","Midwives, nurses, and physicians had diverse approaches to childbirth and breastfeeding (medicalization vs. naturalness) and worked along different jurisdictions that became manifest in strict spatial divisions of maternity units. In their engagement within the BFHI, midwives, nurses, and physicians pursued different strategies (safeguarding vs. circumvention strategies). These differences hindered inter-professional teamwork and collaboration and, therefore, the integration of BFHI into practice."]
["The bumpy road to implementing the Baby-Friendly Hospital Initiative in Austria: a qualitative study","International Breastfeeding Journal","Wieczorek, Christina C., Hermann Schmied, Thomas E. Dorner, and Wolfgang Duer. “The Bumpy Road to Implementing the Baby-Friendly Hospital Initiative in Austria: A Qualitative Study.” International Breastfeeding Journal 10 (2015). https://doi.org/10.1186/s13006-015-0030-0.",2015,"Austria","Hospital","BHFI overall/all steps ","Health workers and hospital management"," To investigate facilitating or hindering factors for BFHI implementation: \n-why maternity units decide to become BFHI-certified,\n-how BFHI is installed at the unit level, \n-and which factors facilitate or impede the operation of the BFHI in Austria and how barriers are overcome.","Interviewees mentioned several motives for selecting the BFHI:\n-BFHI as a marketing tool,\n-improvement of existing services, \n-promote collaboration between different professional groups. \n\n-In each hospital, 'change agents' were identified, who promoted the BFHI, among managers of all professional groups.\n-Becoming BFHI involved the adoption of project management, development and dissemination of new standards, and training of all staff. \n-Although preparation activities were planned to put BFHI into practice, participants mentioned facilitating and  several hindering factors. \n-Interpretations of what facilitated or impeded BFHI differed among and between professional groups."]
["Evaluating the WHO/UNICEF breast-feeding course","BRITISH JOURNAL OF MIDWIFERY","Wissett, L., F. Dykes, and R. Bramwell. “Breast-Feeding. Evaluating the WHO/UNICEF Breast-Feeding Course.” British Journal of Midwifery 8, no. 5 (2000): 294–300.",1993,"UK","Hospital","Step 2","Health workers","Empirical evaluation of the impact of this course on health professionalsâ€™ attitudes and knowledge in relation to breast-feeding.","Statistically significant change in knowledge.\n-@difference in self-@reported attitudes.\n-@the extent of attitude change related to the strength of evidence underpinning each of the Ten Steps to successful breast-@feeding. -@organizational and cultural changes taking place concurrently within the hospital facilitated staff in implementing the BFI."]
["Systematic Review of Evidence for Baby-Friendly Hospital Initiative Step 3: Prenatal Breastfeeding Education","Journal of Human Lactation","Wouk, K., K. P. Tully, and M. H. Labbok. “Systematic Review of Evidence for Baby-Friendly Hospital Initiative Step 3: Prenatal Breastfeeding Education.” Journal of Human Lactation 33, no. 1 (2017): 50–82. https://doi.org/10.1177/0890334416679618.",2017,"Multi-country review","Hospital & Community","Step 3","Prenatal women","To determine whether prenatal clinic- or hospital-based breastfeeding education increases breastfeeding initiation, duration, or exclusivity.","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 womens' partners or family are involved.\n-@Varying Study quality limited the ability to recommend any single intervention as most effective."]
["The effects of a hospital-based perinatal breastfeeding program on exclusive breastfeeding in Taiwan: a quasi-experimental study","Australian Journal of Advanced Nursing ","Yeh, Ching-Hsueh, Ya-Pi Ng Yang, and Bih- O. Lee. “The Effects of a Hospita-Based Perinatal Breastfeeding Program on Exclusive Breastfeeding in Taiwan: A Quasi-Experimental Study.” Australian Journal of Advanced Nursing 37, no. 3 (2020): 20–28.",2020,"Taiwan","Hospital","Prenatal BF step 3","Newborns and postpartum women","To examine if a perinatal breastfeeding program would improve the exclusive breastfeeding rate at a baby-friendly hospital","In the experimental group, 90% of the infants completed the first feeding within two hours after birth. At discharge, 93.3% of the mothers in the experimental group and 53.3% in the control group were exclusively breastfeeding. At one month postpartum, 83.3% of the mothers in the experimental group and 36.7% in the control group were still exclusively breastfeeding."]
["Early initiation and exclusive breastfeeding: Factors influencing the attitudes of mothers who gave birth in a baby-friendly hospital","Turk J Obstet Gynecol","Yılmaz, E., F. Doğa Öcal, Z. Vural Yılmaz, M. Ceyhan, O. Fadıl Kara, and T. Küçüközkan. “Early Initiation and Exclusive Breastfeeding: Factors Influencing the Attitudes of Mothers Who Gave Birth in a Baby-Friendly Hospital.” Turk Jinekoloji ve Obstetrik Dernegi Dergisi 14, no. 1 (2017): 1–9. https://doi.org/10.4274/tjod.90018.",2017,"Turkey","Hospital","BHFI overall/all steps ","Postpartum women","To investigate the initiation time of breastfeeding, exclusive breastfeeding rates, and complementary feeding practices during the first six months of life among mothers who gave birth in a baby-friendly hospital. ","- 97.4% of the mothers initiated breastfeeding, 60.1% within the first hour. \n-EBF for six months in 38.9%.  More than half (61.1%) of the infants were partially/bottle fed for six months; the most common reason was the belief that breast milk was insufficient."]
["Awareness and Attitudes of Health Workers About  Breastfeeding and Baby Friendly Hospital Practices","Turkiye Klinikleri Journal of Pediatrics","Yilmazbaş, P., G. Keskindemirci, Ö Özbörü, B. Kural, İ Cantürk, P. Boran, and G. Gökçay. “Awareness and Attitudes of Health Workers about Breastfeeding and Baby Friendly Hospital Practices.” Turkiye Klinikleri Pediatri 29, no. 3 (2020): 153–58. https://doi.org/10.5336/PEDIATR.2019-72923.",2020,"Turkey","Hospital","BHFI overall/all steps ","Health workers","Baby Friendly Hospital Initiative (BFHI) programme was developed to train health workers, to promote and support breastfeeding. Healthcare providers play a key role in the beginning and continuity in breastfeeding. This study was carried out to determine the knowledge and awareness of health workers about breastfeeding and BFHI.","39.3% of participants (residents health workers, nurses, specialists) had training on breastfeeding at their institution. Almost half of the health workers knew the definition of BFHI and 21.6%  knew the Code of Marketing of Breast Milk Substitutes. This knowledge was significantly lower among residents than specialist and nurses."]
["Japanese trends in breastfeeding rate in baby-friendly hospitals between 2007 and 2010:a retrospective hospital-based surveillance study","BMC Pregnancy and Childbirth","Yoda, T., K. Takahashi, and Y. Yamauchi. “Japanese Trends in Breastfeeding Rate in Baby-Friendly Hospitals between 2007 and 2010: A Retrospective Hospital-Based Surveillance Study.” BMC Pregnancy Childbirth 13 (2013): 207. https://doi.org/10.1186/1471-2393-13-207.",2013,"Japan","Hospital","BHFI overall/all steps ","Newborns and postpartum women","To summarize the breastfeeding rate for all of Japanâ€™s baby-friendly hospitals (BFHs).\n- Identify their strengths in conjunction with the structural and legislative support that they have in place \n-Draw up a policy for dispersing BFH activities to non-BFH delivery facilities, to increase the breastfeeding rate.","The collection rate was 100% in each year (2007, 2008, 2009 and 2010). The breastfeeding rates during hospital stay, at discharge, and one month were >70%, ~90%, and >75%, respectively. The median length of stay was 5 days (minimum/maximum: 5/8) for primipara"]
["Ten Steps to Successful Breastfeeding programme to promote early initiation and exclusive breastfeeding in DR Congo: a cluster-randomised controlled trial","Lancet Global Health","Yotebieng, M., M. Labbok, H. M. Soeters, J. L. Chalachala, B. Lapika, B. S. Vitta, and F. Behets. “Ten Steps to Successful Breastfeeding Programme to Promote Early Initiation and Exclusive Breastfeeding in DR Congo: A Cluster-Randomised Controlled Trial.” Lancet Glob Health 3, no. 9 (2015): e546-55. https://doi.org/10.1016/s2214-109x(15)00012-1.",2015,"Democratic Republic of Congo","Hospital & Community","BHFI overall/all steps ","Newborns and postpartum women","We assessed the effect on breastfeeding outcomes of a short-cut implementation of 'the Ten Steps to Successful Breastfeeding', = key component of the Baby-Friendly Hospital Initiative (BFHI).","Breastfed within 1 h of birth: 76% of infants in the control group, 72% in the steps 1-9 group, and 71% in the steps 1-10 group.\n\n-Prevalence of exclusive breastfeeding at age 14 weeks was: 29% in the control group; 65% in the steps 1-9 group; and 42% in the steps 1-10 group.\n\n-At age 24 weeks, the prevalence of exclusive breastfeeding was 12% in the control group; 36% in the steps 1-9 group; I275and 14% in the steps 1-10 group."]
["Compliance With WHO/UNICEF BFHI Standards in Croatia After Implementation of the BFHI","Journal of Human Lactation","Zakarija-Grkovic, I., M. Boban, S. Jankovic, A. Cuze, and T. Burmaz. “Compliance with WHO/UNICEF BFHI Standards in Croatia after Implementation of the BFHI.” Journal of Human Lactation 34, no. 1 (2018): 106–15. https://doi.org/10.1177/0890334417703367.",2018,"Croatia","Hospital","Steps 3-10","Postpartum women","This study aimed to determine hospital practices and breastfeeding rates before and after BFHI implementation and assess compliance with UNICEF/World Health Organization (WHO) standards for seven of the BFHI's Ten Steps to Successful Breastfeeding (Ten Steps).\n-It is a detailed study of women who gave birth before and after BFHI implementation. The first cohort (A) was recruited  prior to BFHI implementation; the second cohort (B) 3 months after the training of hospital staff; and the third cohort (C) 6 months after the maternity facility received designation as a Baby-Friendly Hospital. Cohorts  A and B were combined as 1 pre-BFHI group, C was post-BFHI.","All 3-10 steps improved significantly post-BFHI. Step 3 (â€œantenatal educationâ€\u009d) showed the least improvement, whereas Step 7 (rooming-in; 2.6% pre-BFHI vs. 98.5% post-BFHI) and Step 9 (no pacifiers/teats\u009d; 21.8% pre-BFHI vs. 99.4% post-BFHI) showed the greatest improvement. \n-Six months after BF designation, standards dropped and only Steps 7 and 9 were in full compliance with UNICEF/WHO standards. In-hospital, exclusive-breastfeeding rates rose markedly (p < .001), but no change occurred in breastfeeding rates at 3, 6, or 12 months."]
["Hospital Practices and Breastfeeding  Rates before and after the UNICEF/ WHO 20-Hour Course for Maternity Staff","Journal of Human Lactation","Zakarija-Grkovic, I., O. Segvic, T. Bozinovic, A. Cuze, T. Lozancic, A. Vuckovic, and T. Burmaz. “Hospital Practices and Breastfeeding Rates before and after the UNICEF/WHO 20-Hour Course for Maternity Staff.” Special Issue: WHO/UNICEF’s Baby-Friendly Initiative. 28, no. 3 (2012): 389–99. https://doi.org/10.1177/0890334412447079.",2012,"Croatia","Hospital","Becoming/pre BFHI","Newborns and postpartum women","To evaluate the impact of BFHI training on hospital practices and breastfeeding rates during the first 12 months of life.","3 months after training was completed, Step 4, Initiate breastfeeding within a half-hour of birth; Step 7, Rooming-in; and Step 8, Feeding on demand\u009d had significantly improved. \n\nNewborns exclusively breastfed during the first 48 hours increased from 6.0% to 11.7% (P < .005).\n \nThere was no difference in breastfeeding rates at discharge or at 3, 6, or 12 months between the pre- and post-training groups."]
["Babyâ€\u0090friendly hospital practices are associated with duration of full breastfeeding in primiparous but not multiparous Iranian women","Maternal & Child Nutrition","Zarshenas, M., Y. Zhao, C. W. Binns, and J. A. Scott. “Baby-Friendly Hospital Practices Are Associated with Duration of Full Breastfeeding in Primiparous but Not Multiparous Iranian Women.” Matern Child Nutr 14, no. 3 (2018): e12583. https://doi.org/10.1111/mcn.12583.",2018,"Iran","Hospital","BHFI overall/all steps ","Postpartum women","This study investigated the impact of BFHI practices on duration of full breastfeeding in a cohort of 700 Iranian mothers recruited between June 2014 and March 2015 from maternity hospitals in Shiraz and followedâ€\u0090up prospectively for 6 months. ","-Mothers reported experiencing on average 3.9 Steps, and only 28% of infants were fully breastfed at 6 months. \n-There was a protective inverse relationship for primiparous  but not multiparous mothers, between the number of Steps a woman was exposed to and the likelihood of her discontinuing full breastfeeding within 6 months postpartum. \n-Greater exposure to BFHI practices potentially could increase primiparous mothers' chances of fully breastfeeding to 6 months. "]
["Determinants of in-hospital feeding practices in Shiraz, Iran: Results of a prospective cohort study","Birth","Zarshenas, M., Y. Zhao, C. W. Binns, and J. A. Scott. “Determinants of In-Hospital Feeding Practices in Shiraz, Iran: Results of a Prospective Cohort Study.” Birth 46, no. 1 (2019): 137–45. https://doi.org/10.1111/birt.12385.\n",2019,"Iran","Hospital","BHFI overall/all steps ","Postpartum women","Aim is to report the prevalence and determinants of delayed breastfeeding, provision of traditional pre-lacteal foods, and use of infant formula in hospital.","Only 32.2% of infants were breastfed within 1 hour of birth, with 40.8% receiving a traditional prelacteal food, and 34.9% given formula during their hospital stay.  "]
["Barriers and facilitators to implementing the Baby-Friendly hospital initiative in neonatal intensive care units\n","JOGNN\n","Zivich, P., Lapika, B., Behets, F., & Yotebieng, M. \"Implementation of steps 1–9 to successful breastfeeding reduces the frequency of mild and severe episodes of diarrhea and respiratory tract infection among 0–6 month infants in Democratic Republic of Congo.\" Maternal and child health journal (2018) 22(5), 762-771.","2018\n","Democratic Republic of Congo","Health Centres","Steps 1-9 versus Steps 1-10 comparison","Newborns","The aim of this study was to assess the effect of implementing Baby-Friendly Hospital Initiative (BFHI) steps 1–9 and BFHI steps 1–10 on incidence of diarrhea and respiratory illnesses in the first 6 months of life. Methods We reanalyzed a cluster randomized trial in which health-care clinics in Kinshasa, Democratic Republic of Congo, were randomly assigned to standard care (control group), BFHI steps 1–9, or BFHI steps 1–10. Outcomes included episodes of diarrhea and respiratory illness. ","Results Steps 1–9 was associated with a decreased incidence of reported diarrhea (IRR 0.72, 95% CI 0.53, 0.99) and respiratory illness (IRR 0.48, 95% CI 0.37, 0.63), health facility visits due to diarrhea (IRR 0.60, 95% CI 0.42, 0.85) and respiratory illness (IRR 0.47, 95% CI 0.36, 0.63), and hospitalizations due to diarrhea (IRR 0.42, 95% CI 0.17, 1.06) and respiratory illness (IRR 0.33, 95% CI 0.11, 0.98). Addition of Step 10 attenuated this effect: episodes of reported diarrhea (IRR 1.24, 95% CI 0.93, 1.68) and respiratory illness (IRR 0.77, 95% CI 0.60, 0.99), health facility visits due to diarrhea (IRR 0.76, 95% CI 0.54, 1.08) and respiratory illness (IRR 0.75 95% CI 0.57, 0.97), and hospitalizations due to respiratory illness (IRR 0.48 95% CI 0.16, 1.40); but strengthened the effect against hospitalizations due to diarrhea (IRR 0.14, 95% CI 0.03, 0.60). Conclusions Implementation of steps 1–9 significantly reduced incidence of mild and severe episodes of diarrhea and respiratory infection in the first 6 months of life, addition of step 10 appeared to lessen this effect."]