Baby-Friendly Hospital Initiative Accreditation Research Articles

Investigating midwives and nurses reporting of ‘infant feeding at hospital discharge’: an online survey across NSW Australia

BackgroundThe collection of data on ‘infant feeding at hospital discharge’ is used to monitor breastfeeding outcomes, health service benchmarking, and research. While some Australian states have clear definitions of this data collection point, there is no operational definition of ‘infant feeding at hospital discharge’ in the Australian state of New South Wales. Little is known about how midwives interpret the term ‘infant feeding at hospital discharge’, in particular, the timeframe used to calculate these important indicators. The purpose of this study was to explore midwives’ and nurses’ practices of reporting ‘infant feeding at hospital discharge’ in the Australian state of New South Wales.MethodsAn online survey was distributed across public and private maternity hospitals in New South Wales, Australia. The survey asked midwives and nurses their practice of reporting ‘infant feeding at discharge’ from categories offered by the state Mothers and Babies report of either “full breastfeeding”, “any breastfeeding”, and “infant formula only”. The Qualtrics survey was available from December 2021 to May 2022.ResultsThere were 319 completed surveys for analysis and all 15 NSW Health Districts were represented. Some participants reported using the timeframe ‘since birth’ as a reference (39%), however, the majority (54%, n = 173) referenced one of the feeding timeframes within the previous 24 h. Most midwives and nurses (83%, n = 265) recommended 24 h before discharge as the most relevant reference timeframe, and 65% (n = 207) were in favour of recording data on ‘exclusive breastfeeding’ since birth.ConclusionThis study identified multiple practice inconsistencies within New South Wales reporting of ‘infant feeding at hospital discharge’. This has ramifications for key health statistics, state reporting, and national benchmarking. While the Baby Friendly Hospital Initiative accreditation requires hospitals to demonstrate and continuously monitor at least a 75% exclusive breastfeeding rate on discharge, only 11 New South Wales facilities have achieved this accreditation. We recommend introducing an option to collect ‘exclusive breastfeeding’ on discharge’ which is in line with participant recommendations and the Baby Friendly Hospital accreditation. Other important considerations are the updated World Health Organization indicators such as, “Ever breastfed”; “Early initiation of breastfeeding” (first hour); “Exclusively breastfed for the first two days after birth”.

Baseline status regarding compliance with neo-BFHI recommendations in South African neonatal wards: a cross-sectional survey

BackgroundIn 2009, the World Health Organization and the United Nations Children’s Fund issued a revised Baby-friendly Hospital Initiative (BFHI) package to encourage all healthcare facilities to promote the advice of exclusive breastfeeding. The scope of the BFHI was expanded to include neonatal units by the Nordic and Quebec Working Group.AimTo determine the level of compliance with the recommendations outlined in the “Baby-friendly Hospital Initiative for neonatal wards” (Neo-BFHI) in the South African neonatal wards.MethodIn this cross-sectional survey, the sample included neonatal wards (N = 33) from public and private hospital facilities. Using EasyTrial software, the Neo-BFHI self-assessment questionnaire was utilized to collect the data. The data was transferred to MS Excel (version 15.0.5127.1000) and analysed with the Statistical Package for Social Sciences version 24.ResultsThe South African median score for Neo-BFHI compliance was 77. Neonatal wards in public hospitals scored higher (85) than those in private hospitals (73). Neonatal wards in hospitals that were accredited Baby-friendly had higher compliance scores than those without accreditation. The country had the highest compliance scores (100, 90) on Guiding Principle 1 (respect towards mothers) and step 5 (breastfeeding support), respectively. However, it scored low (71, 58) on steps 4 (enhancing kangaroo mother care) and 7 (maternal infant “togetherness”), respectively. Level 1 and 2 care facilities scored significantly higher than level 3.ConclusionAlthough South Africa successfully implemented the Neo-BFHI recommendations, private hospitals had a smaller number of BFHI-accredited facilities and lower compliance than public hospitals. Strategies should be developed to strengthen and improve BFHI accreditation and compliance, particularly in private hospitals.

Predicting exclusive breastfeeding in maternity wards using machine learning techniques

Background and objectiveAdequate support in maternity wards is decisive for breastfeeding outcomes during the first year of life. Quality improvement interventions require the identification of the factors influencing hospital benchmark indicators. Machine Learning (ML) models and post-hoc Explainable Artificial Intelligence (XAI) techniques allow accurate predictions and explaining them. This study aimed to predict exclusive breastfeeding during the in-hospital postpartum stay by ML algorithms and explain the ML model’s behaviour to support decision making. MethodsThe dataset included 2042 mothers giving birth in 18 hospitals in Eastern Spain. We obtained information on demographics, mothers’ breastfeeding experiences, clinical variables, and participating hospitals’ support conditions. The outcome variable was exclusive breastfeeding during the in-hospital postpartum stay. We tested algorithms from different ML families. To evaluate the ML models, we applied 10-fold stratified cross-validation. We used the following metrics: Area under curve receiver operating characteristic (ROC AUC), area under curve precision-recall (PR AUC), accuracy, and Brier score. After selecting the best fitting model, we calculated Shapley’s additive values to assign weights to each predictor depending on its additive contribution to the outcome and to explain the predictions. ResultsThe XGBoost algorithms showed the best metrics (ROC AUC = 0.78, PR AUC = 0.86, accuracy = 0.75, Brier = 0.17). The main predictors of the model included, in order of importance, the pacifier use, the degree of breastfeeding self-efficacy, the previous breastfeeding experience, the birth weight, the admission of the baby to a neonatal care unit after birth, the moment of the first skin-to-skin contact between mother and baby, and the Baby-Friendly Hospital Initiative accreditation of the hospital. Specific examples for linear and nonlinear relations between main predictors and the outcome and heterogeneity of effects are presented. Also, we describe diverse individual cases showing the variation of the prediction depending on individual characteristics. ConclusionThe ML model adequately predicted exclusive breastfeeding during the in-hospital stay. Our results pointed to opportunities for improving care related to support for specific mother’s groups, defined by current and previous infant feeding experiences and clinical conditions of the newborns, and the participating hospitals’ support conditions. Also, XAI techniques allowed identifying non-linearity relations and effect’s heterogeneity, explaining specific cases’ risk variations.

Baby Friendly Hospital Initiative Breastfeeding Outcomes in Mothers with COVID-19 Infection During the First Weeks of the Pandemic in Spain.

Adherence to the Ten Steps of the Baby-Friendly Hospital Initiative has been shown to have a protective role for the initiation and maintenance of breastfeeding. (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 Baby-Friendly Hospital Initiative accreditation. This was a two-group comparative longitudinal observational study of infants born to mothers with COVID-19 at the time of birth, between March 13-May 31, 2020 (the first wave of the pandemic) in Spain. Fourteen Spanish hospitals participated, five (35.7%) were Baby-Friendly Hospital Initiative accredited. Type of feeding was assessed prospectively at discharge, 1, 3, and 6 months of age. A total of 248 newborns were included in the study. 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. The 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.

Social value of maintaining baby-friendly hospital initiative accreditation in Australia: case study

BackgroundBreastfeeding has positive impacts on the health, environment, and economic wealth of families and countries. The World Health Organization (WHO) launched the Baby Friendly Hospital Initiative (BFHI) in 1991 as a global program to incentivize maternity services to implement the Ten Steps to Successful Breastfeeding (Ten Steps). These were developed to ensure that maternity services remove barriers for mothers and families to successfully initiate breastfeeding and to continue breastfeeding through referral to community support after hospital discharge. 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.MethodThe study was non-experimental and was conducted in the maternity unit of Calvary Public Hospital, Canberra, an Australian BFHI-accredited public hospital with around 1000 births annually. This facility provided an opportunity to illustrate costs for maintaining BFHI accreditation in a relatively affluent urban population. Stakeholders considered within scope of the study were the mother-baby dyad and the maternity facility. We interviewed the hospital’s Director of Maternity Services and the Clinical Midwifery Educator, guided by a structured questionnaire, which examined the cost (financial, time and other resources) and benefits of each of the Ten Steps. Analysis was informed by the Social Return on Investment (SROI) framework, which consists of mapping the stakeholders, identifying and valuing outcomes, establishing impact, calculating the ratio and conducting sensitivity analysis. This information was supplemented with micro costing studies from the literature that measure the benefits of the BFHI.ResultsThe 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.ConclusionsScaled 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.

Understanding factors affecting breastfeeding practices in one city in the Kingdom of Saudi Arabia: an interpretative phenomenological study

BackgroundBreastfeeding duration has declined in the Kingdom of Saudi Arabia (KSA) in recent decades, although accurate national data about different breastfeeding indicators by infant age are lacking. This qualitative study, the first in KSA, aimed to understand the factors affecting mothers’ decisions and experiences regarding any breastfeeding practices.MethodsA qualitative phenomenological approach was used to investigate mothers’ experiences of breastfeeding. Non-probability convenience sampling and snowballing strategies were designed to recruit participants. Semi-structured interviews were conducted with 16 mothers, from two hospitals and three primary health clinics in Al-Madinah city, from December 2017 to March 2018. Interpretative phenomenological analysis was the analysis framework.ResultsThree themes were identified: 1) ‘Up against the system’: policies, staff and systems were the main barriers to exclusive breastfeeding; 2) ‘Social support and negativity’: family support in the first 40 postpartum days protected breastfeeding continuation and was highly appreciated, but negative comments limited breastfeeding practices thereafter; and 3) ‘Managing tensions’: mothers’ religious beliefs about breastfeeding boosted their decisions; however, the challenge of managing tensions influenced mothers to stop breastfeeding earlier than they wished. The study revealed that mothers had no doubts about wanting to breastfeed their babies; but continuation was adversely affected by unhelpful hospital policies and staff actions, the lack of ongoing social support, and by others people’s negativity, rather than by the mothers’ own views. Stopping breastfeeding earlier than planned was a complex decision for most mothers. However, mothers said that they intended to breastfeed their next baby successfully.ConclusionsHealthcare professionals (maternity staff, paediatricians and pharmacists) need education and training to support exclusive breastfeeding effectively. Increasing the number of hospitals with Baby Friendly Hospital Initiative accreditation, which includes staff practice changes, is needed to protect and support exclusive breastfeeding. Ongoing professional and peer support, and improving conditions at workplaces and universities, are needed to help mothers to continue breastfeeding successfully. Effective, coordinated national policies can support mothers’ decisions in relation to breastfeeding. Such changes will reduce the tensions experienced by women and help them to achieve their breastfeeding goals and to breastfeed for longer.

Maternal Country of Birth and Exclusive Breastfeeding During the First In-Hospital Day in Portugal: The Influence of the Baby-Friendly Hospital Initiative.

Early breastfeeding practices are important determinants of later breastfeeding behaviors and can be influenced by multiple factors. Despite the Baby-Friendly Hospital Initiative reported positive influence on breastfeeding initiation, its influence on the association between maternal country of birth and first day in-hospital breastfeeding has not been examined. 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. Data were drawn from baMBINO-a longitudinal, 2017-2019 nationwide study designed to assess the perinatal health and healthcare experiences of migrant and native Portuguese women. Data from participants (N = 5,340) were collected during their hospital stay from 32 maternity units. Missing data were handled through multiple imputation. After stratifying by Baby-Friendly Hospital Initiative accreditation, a multivariate logistic regression was performed. 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 breastfeeding during the first 24 hr. The Baby-Friendly Hospital Initiative attenuates differences between migrant and native participants, promoting optimal breastfeeding practices among natives.

Baby-friendly hospital initiative accreditation in Taiwan: Challenges and assistance needs

Baby-friendly hospital initiative accreditation in Taiwan: Challenges and assistance needs

The Baby-friendly Hospital Initiative and Qatar, 2016.

Breastfeeding instills countless benefits that extend beyond the infant and child to the entire nation. One of the global targets set by the WHO to improve maternal, infant, and young child nutrition is to increase the rate of exclusive breast-feeding “in the first 6 months” up to at least 50% by 2025.3 Thus, as a global endeavor to promote and sustain breastfeeding, the WHO and UNICEF launched the Baby-friendly Hospital Initiative (BFHI) 1 year after the Innocenti Declaration of 1990. Regarding the State of Qatar, there was a 34% rate of early initiation of breastfeeding “within the first hour of birth” and a 29% rate of exclusive breastfeeding between 2010 and 2015. In Qatar during 2016, many obstacles in achieving the aforementioned global target remained. In addition, there are still no hospitals with a BFHI accreditation.

Predictors of breastfeeding exclusivity and duration in a hospital without Baby Friendly Hospital Initiative accreditation: A prospective cohort study.

The aim of this study was to investigate the maternity care factors associated with exclusive breastfeeding duration at three months and six months postpartum in a setting without BFHI accrediation. A prospective cohort design. Participants from one tertiary maternity hospital were eligible if they intended to exclusively breastfeed, had birthed a live, term baby; were breastfeeding at recruitment; were rooming-in with their baby; were healthy and well; and understood English. Participants completed an infant feeding survey using 24-h recall questions at three time-points. Data were analysed using descriptive statistics, bivariate analysis and regression modelling. We recruited 424 participants of whom 84% (n=355) responded to the survey at 3-months and 79% (n=335) at 6-months. Women who avoided exposure to intrapartum opioid analgesia (e.g. intramuscular, intraveous or epidural) were more likely to be exclusively breastfeeding at 3-months postpartum (adjusted odds ratio (aOR) 2.09, 95% confidence interval (CI) 1.15-3.80, probability value (p) 0.016). The only other modifiable predictor of exclusive breastfeeding at 3-months was non-exposure to artificial formula on the postnatal ward (aOR 2.44, 95% CI 1.43-4.18, p<0.001). At 6-months postpartum, the rate of exclusive breastfeeding had reduced to 5% (n=16) which rendered regression modelling untenable. Strategies to decrease exposure to opioid analgesia in birth settings and the use of infant formula on the postnatal ward may improve exclusive breastfeeding at three months. Results suggest that both intrapartum and postpartum maternity care practices can predict long-term breastfeeding success.

Breastfeeding Support in Spanish Neonatal Intensive Care Units and the Baby-Friendly Hospital Initiative.

The Baby-Friendly Hospital Initiative (BFHI) has a positive effect on breastfeeding in maternity wards; however, few studies have examined to what degree it affects care in neonatal intensive care units (NICUs). Recently, the BFHI has been adapted to the NICUs (Neo-BFHI). This study aimed 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). A validated questionnaire on breastfeeding support was distributed to level II and III NICUs in Spanish public hospitals. A univariate analysis and an analysis adjusted for the number of beds in NICUs were conducted. The results of the analysis of 36 breastfeeding support measures are presented in accordance with the Ten Steps to Successful Breastfeeding adapted to NICUs. Of the 141 participating NICUs, 129 (91%) responded to the questionnaire: 38 NICUs from group 1 and 91 NICUs from group 2. Group 1 had implemented a higher number of breastfeeding support measures than group 2. There were significant differences in 18 measures related to steps 2, 4, 5, 7, and 8 of the Neo-BFHI. In 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. The Spanish NICUs in hospitals with BFHI accreditation or in the process of being accredited have better implementation of practices to promote and support breastfeeding.

The New Zealand/Aotearoa Baby-Friendly Hospital Initiative Implementation Journey

The Baby-Friendly Hospital Initiative (BFHI) was launched by the World Health Organization and United Nations International Children's Emergency Fund in 1991 following the Innocenti Declaration of 1990, of which New Zealand/Aotearoa was a signatory. After a number of unsuccessful attempts to implement BFHI by breastfeeding advocates, the New Zealand Breastfeeding Authority (NZBA) was established in 1999. 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, Māori 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%). Future strategies focus on having all relevant community providers achieve Baby-Friendly Community Initiative accreditation and on the NZBA's lobbying the government for initiatives that support, promote, and protect breastfeeding.

Baby-Friendly Hospital Accreditation, In-Hospital Care Practices, and Breastfeeding

To investigate the effect of Baby-Friendly Hospital Initiative (BFHI) accreditation and hospital care practices on breastfeeding rates at 1 and 4 months. 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. 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 in-hospital 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. 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.

Perception of maternity staff toward baby‐friendly hospital initiative accreditation

The Baby Friendly Hospital Initiative (BFHI) requires hospitals to create an environment conducive to breastfeeding for postpartum mothers. Baby‐Friendly hospitals have shown significant improvement of breastfeeding rates. This study describes staff's underlying beliefs that can promote or hinder BFHI accreditation. A sample of 20 maternity staff was recruited from 10 southern New Jersey hospitals during spring 2011, and completed a questionnaire framed under the theory of planned behavior. Six open‐ended questions were asked about BFHI process: two each to elicit behavioral, normative, and control beliefs. Participants were white females, 21.5±8.6 years of experience in maternity; 55% having post college education; 55% working toward BFHI accreditation in their facilities. Content analysis examined texts provided by respondents. Frequently mentioned consequence of accreditation was “increased breastfeeding rates, 65%”.” “Benefit to mom/baby, 80%” was the most frequently mentioned reason for supporting accreditation; whereas “resistant to change, 75%” was for disapproving it. Disapproving referents included administrators, 35% and physicians/pediatricians, 30%. Most mentioned barriers were “costly, 45%” and “ignorance, 45%.” Findings can be used to develop a quantitative instrument determining influential beliefs, thus providing directions for effective accreditation procedures.