Baby-Friendly Hospital Initiative Implementation Research Articles

Assessment of the Baby-Friendly Hospital Initiative showed suboptimal knowledge and a low exclusive breastfeeding rate in Ogun State, Nigeria.

Implementing the Baby-Friendly Hospital Initiative (BFHI) programme has been fraught with challenges globally. The study aimed to assess the implementation of the BFHI and breastfeeding practices in healthcare facilities in Ogun State, Nigeria. It was a questionnaire-based cross-sectional study carried out between August and October 2019 among 100 healthcare workers and 110 mothers from health facilities in Ijebu-Ode Local Government Area of Ogun State, Nigeria. Nearly two-thirds (61.0%) of the healthcare workers were community health workers while the others were nurses. Less than a quarter (23.8%) of the healthcare workers had ever attended breastfeeding educational programmes since they started working. About half of the healthcare workers had good knowledge, attitude and practice of BFHI. Nurses had a significantly better practice of BFHI than community health workers. Understaffing was a major limitation to the implementation of BFHI. The mothers had an exclusive breastfeeding rate of 47%. The knowledge, attitude, and practice of BFHI were suboptimal and the exclusive breastfeeding rate among the mothers was low. There is a need to improve staff strength, training and re-training of staff, as well as regular monitoring and evaluation of healthcare facilities on the implementation of BFHI.

The Baby Friendly Hospital Initiative in Canada: A Narrative Review

Breastfeeding offers substantial benefits to infant health, encompassing physical and neurodevelopmental aspects. National and international guidelines, such as those from the Canadian Paediatric Society (CPS) and World Health Organization (WHO), recommend exclusive breastfeeding for the first six months of life, followed by continued breastfeeding with complementary foods until two years of age or beyond. Despite these recommendations, Canada faces challenges in achieving optimal breastfeeding rates, with only 35% of parents exclusively breastfeeding until the recommended six-month mark. This narrative review aims to assess the implementation rate of the Baby-Friendly Hospital Initiative (BFHI) in Canada, an intervention established by the WHO and the United Nations Children’s Fund (UNICEF) to promote breastfeeding. Comprehensive searches on Google and official websites of relevant associations and organizations were conducted to gather data on the number of designated Baby-Friendly Hospitals using reports from 2016 to 2022. Our findings reveal that only 3% of the 604 total hospitals in Canada available for receiving Baby-Friendly designation have acquired it. Furthermore, the proportion of designated hospitals is less than one-third in each province. There are varying trends in the number of designated Baby-Friendly Hospitals across Canadian provinces and territories. While some have demonstrated a steady increase over the examined period (e.g. Nova Scotia, Alberta), others exhibited a decline or no change (e.g. Ontario, Prince Edward Island). Several factors may have contributed to the low numbers and trends in BFHI designation, including the COVID-19 pandemic, lack of BFHI implementation in hospital accreditation requirements, and the dispersed efforts towards BFHI-related activities. These results underscore the urgent need for enhanced implementation of the BFHI across Canada.

Implementation of the Baby-Friendly Hospital & Community Initiatives in Europe: a scoping review

Abstract Background Promotion of and support for breastfeeding is essential for public health, to improve nutrition globally and save the lives of over 800,000 children annually. Since its launch in 1991, the Baby-Friendly Hospital Initiative (BFHI) has been implemented in 150 countries, to promote the ‘ten steps to successful breastfeeding', with the Baby-Friendly Community Initiative (BFCI), arising from the 10th step. Aim To synthesise evidence about BFHI and BFCI implementation in European countries. Methods This scoping review was conducted according to the Joanna Briggs Institute methodology for scoping reviews. Data were charted by country, study design, setting, study population, BFHI steps, study aim and objectives, intervention, results, barriers and enablers to implementation, evidence gaps, and recommendations. Qualitative and quantitative descriptive analyses were undertaken. Results A total of 278 articles were included in the review, of which 60 studies covered the implementation of the BFHI or BFCI in 18 European countries. Most studies were found from the UK (n = 11) Italy (n = 9) and Switzerland, Spain and Turkey (n = 6 each). Most were hospital-only based (n = 48) and most covered all ten steps of the BFHI (n = 44) and fewer BFCI (n = 4). Studies were carried out with health workers (n = 17), mothers (n = 34) and policy makers. Most studies were quantitative (n = 39) with many others designs used. Our charting of results highlights that effective implementation required political commitment, legislative and regulatory underpinning; support at organisational level; ongoing multi-professional leadership, education, training and teamwork, and effective education for women. Conclusions While contextual country-level factors are seen, there are clear patterns underpinning successful BFHI/ BFCI implementation, which can guide effective implementation. Funded by the Irish Research Council and Department of Foreign Affairs Ireland, grant number: COALESCE/2019/89 Key messages • Strong political and professional leadership is required to support the effective implementation of public health initiatives to support breastfeeding. • Ongoing, effective multi-professional education and training is required to support breastfeeding.

Allattamento e presenza della persona a scelta della donna durante la pandemia da COVID-19 in Italia: dati correnti regionali e buone pratiche alla nascita.

to describe the monthly trend of breastfeeding during hospitalization and the presence of companion of woman's choice during labour and birth, and the key regional responders' perspective of homogeneity/heterogeneity of the presence of the support person, before, during (February-May 2020), and after the first COVID-19 pandemic wave in a few Italian Regions. two-phase study. data from the italian birth certificate of six Italian Regions between 01.01.2019 and 31.03.2021 were analysed. Semi-structured interviews were conducted with the key regional respondents. the frequency distributions of breastfeeding and the presence of companion of woman's choice were calculated as a whole and for each Region. the infant feeding practices experienced smaller changes during COVID-19 pandemic than the presence of the companion of woman's choice during labour and birth, from January 2019 to March 2021. The highest value of exclusive breastfeeding was recorded in September 2020 (72.1%; 95%CI 71.3-72.8) in all Regions, while the lowest was recorded in March 2021 (62.5%; 95%CI 61.5-63.4). The presence of companion of woman's choice during labour and birth decreased during the pandemic and did not return to pre-pandemic levels. The highest value of presence of father during birth was recorded in March 2019 (59.0%; 95%CI 58.2-59.8), while the lowest in April 2020 (50.0%; 95%CI 49.1-50.8). The main emerging themes were: the existence of national, regional and local indications; the facilitators (e.g., Baby-Friendly Hospital Initiative implementation, strong motivation of the staff) and the critical points (e.g., inadequate analysis of the clinical-epidemiological context, inhomogeneous indications) of management of the support person presence. the emergency has changed the provision of health services that not always guaranteed the application of best practices. It would be desirable to work for assessing the appropriateness of the birth certificate data to collect more accurate information and to provide clinical recommendations.

Barriers and Strategies for Successful Implementation of Baby-Friendly Hospital Initiative: A Scoping Review

IntroductionImplementation of the Baby-Friendly Hospital Initiative (BFHI) with maternal and/or neonatal services in all health care facilities is valuable to protect, promote and support breastfeeding and the well-being of young children. It is essential 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.MethodsA scoping review of evidence-based literature was undertaken. A total of 44 articles on BFHI published globally between the years 2000 and 2021 were reviewed and analyzed.ResultsThe 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. The strategies for successful implementation of BFHI include health care providers’ leadership, teamwork/collaboration, adequate staffing and financial resources, education, mentoring and skills training opportunities for healthcare professionals, continuous monitoring of the BFHI steps, compliance with every step of BFHI, mother-centred approach, and regulation on marketing and sale of breastmilk.ConclusionsGThe role of multi-layered interventions, interdisciplinary collaboration and partnership-based approach is critical in minimizing barriers and promoting the successful implementation of BFHI in all healthcare settings.

Differences in Exclusive Breastfeeding Rates in US Hospitals According to Baby-Friendly Hospital Initiative Designation and Area Deprivation Index Category.

Background: Disparities in breastfeeding persist placing a greater burden of disease on non-Hispanic black and Hispanic women and infants. Targeted implementation of the Baby-Friendly Hospital Initiative (BFHI) in areas at risk for poor breastfeeding outcomes has been shown to improve disparities in breastfeeding. The area deprivation index (ADI), a measure of the relative socioeconomic disadvantage of a neighborhood, may be useful in exploring the accessibility of BFHI hospitals in highly deprived areas and the differences in exclusive breastfeeding (EBF) rates in hospitals with and without the BFHI designation across deprivation categories. Objective: To evaluate the geographical distribution of BFHI and non-BFHI hospitals across ADI categories and explore the differences in EBF rates in BFHI and non-BFHI hospitals across ADI categories. Methods: Hospital EBF rates obtained from the Joint Commission included 414 BFHI and 1,532 non-BFHI hospitals. State ADI rank scores were determined for each hospital's census block group. Descriptive statistics were used to describe the geographic distribution of BFHI hospitals across three ADI categories (low, medium, and high). EBF rates across ADI categories and BFHI designations were compared using multiway analysis of variance. Results: The distribution of BFHI was similar across all ADI categories, ranging from 18% to 24%. EBF rates were 4.9% lower in highly deprived areas compared to areas with lower deprivation (p < 0.01). BFHI was associated with significantly higher EBF rates across all ADI categories (6.9%-11.2%, p < 0.01). Conclusion: ADI may be a useful tool for targeting the implementation of BFHI in hospitals in highly deprived areas to reduce breastfeeding disparities.

Effects of a \u2018Baby-Friendly Hospital Initiative\u2019 on exclusive breastfeeding rates at a private hospital in Lebanon: an interrupted time series analysis

BackgroundExclusive breastfeeding (EBF) through six months of age has been scientifically validated as having a wide range of benefits, but remains infrequent in many countries. The WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI) is one approach to improve EBF rates.MethodsThis 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 process of launching the BFHI at CMC is discussed from the perspective of key stakeholders using the SQUIRE guidelines for reporting on quality improvement initiatives. As an objective measure of the program’s impact, 2,002 live births from July 2015 to February 2018 were included in an interrupted time series analysis measuring the rates of EBF at discharge prior to, during, and following the bundle of BFHI interventions.ResultsThe steps necessary to bring CMC in line with the BFHI standards were implemented during the period between 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, the observed 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.ConclusionsMeeting the BFHI standards is a complex process for a health facility, requiring changes to policies, practices, and infrastructure. Despite many challenges, the results of the interrupted time series analysis indicate that the BFHI reforms were successful in increasing the EBF rate among CMC’s patients and sustaining that rate over time. These results further support the importance of the hospital environment and health provider practices in breastfeeding promotion, ultimately improving the health, growth, and development of newborns.

Robust estimation of infant feeding indicators by data quality assessment of longitudinal electronic health records from birth up to 18 months of life

Background and objectiveThe Baby-Friendly Hospital Initiative (BFHI) is an international strategy aimed at improving breastfeeding practices in health care services. Regular monitoring of indicators is key for BFHI implementation and maintenance. Currently, routine data collected from electronic health records (EHR) is an excellent source for infant feeding monitoring, however data quality (DQ) assessment should be undertaken. The aim of this research is to enable robust estimations of infant feeding indicators through DQ assessment of routine EHR data. Materials and methodsWe use the longitudinal series of healthcare contacts belonging to 6427 children born from 2009 to 2018 in the Health Area V of Murcia (Spain). Longitudinal data came from EHR at hospital discharge and community infant health reviews up to 18 months. The data of each healthcare contact contained a 24-h recall of infant feeding. We perform a DQ process in three phases: (1) an assessment of each-single-contact and the definition of their infant feeding status; (2) a longitudinal DQ assessment of completeness and consistency of the series of contacts to obtain meta-information that guides the duration calculus, for each case, of the different types of breastfeeding: exclusive breastfeeding (EBF), full breastfeeding (FBF) and any breastfeeding (ABF); and finally (3) a robust estimation of indicators and description of DQ of each indicator. ResultsWe found deficiencies of DQ in 30.42% of single contacts for EBF, 19.02% for FBF and 22.50% for ABF that were used to establish the infant feeding status. However, after longitudinal DQ assessment, we obtained valid and reliable data rates for most indicators such as “median duration of breastfeeding” nearly 90%, both for FBF and ABF, not so for EBF. ConclusionsDespite the DQ deficiencies found in raw data, the DQ assurance approach by indicators proposed in this work, allowed us to obtain a robust estimation of indicators with a significant percentage of subjects with valid information for ABF and FBF monitoring. The estimations were consistent with results previously published. The methodology provided with this study allows a continuous and reliable population monitoring of infant feeding indicators of BFHI from routine EHR data.

Racial Disparities in Sustaining Breastfeeding in a Baby-Friendly Designated Southeastern United States Hospital: An Opportunity to Investigate Systemic Racism.

Background: Racial disparities in breastfeeding rates persist in the United States with Black women having the lowest rates of initiation and continuation. A literature review attributes this to many factors-historical roles, cultural norms, lack of social support, and systemic racism in the health care and lactation support system. The Baby-Friendly Hospital Initiative (BFHI) is an evidence-based program to increase breastfeeding through standardized protocols, and, in a Southeastern U.S. academic center, it was associated with increased breastfeeding, but the effect on racial disparities in breastfeeding was unknown. Methods: 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. Results: After BFHI implementation, mothers were overall 1.17 (95% confidence interval: 1.13-1.19) 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 nonBlack mothers (69.4% versus 84.6%, p < 0.0001). Several demographic and medical comorbidities were significantly associated with failure to sustain breastfeeding to hospital discharge. When controlling for these factors, the racial disparity persisted. Conclusions: Since 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, but in the context of the current literature, also reveals the need for further work to ensure interventions are culturally competent and delivered equitably to support sustained breastfeeding for Black women.

Research Title: Factors Associated with Cessation of Exclusive Breastfeeding.

PurposeThe study aimed to determine the prevalence of exclusive breastfeeding (EBF), measure the association between EBF and sociodemographic and obstetric characteristics of lactating mothers, and determine challenges of EBF.MethodsThe study was cross-sectional and was conducted in four primary health care centres (PHCCs) at Alehsa region in Saudi Arabia (SA). Lactating mothers coming to vaccinate their babies (0–6 months) were recruited. Sample size totalled 372, where 93 were randomly selected from each centre. Sociodemographic and obstetric characteristics of participants, breastfeeding (BF) status, and challenges of EBF were collected. Basic univariate descriptive statistics were conducted to explore the sociodemographic and obstetric characteristics, BF status and challenges of BF. Bivariate analyses were done to explore the association between the dependent and independent variables. Binary logistic regression models were then executed. A 2-tailed p-value < 0.05 was considered significant.ResultsEBF rate was nearly 60%. Cessation of EBF was associated with younger age, inconvenience/fatigue due to BF, sore breasts or nipples/too painful, perceived low milk quantity, BF skills were not effective, maternal choice, and baby-centred factors.Conclusion and RecommendationsEBF was associated with problems/difficulties in BF technique. It is recommended that health care professionals like doctors, nurses, and midwives should train mothers during and after pregnancy regarding BF technique or pumping breast milk in case of BF difficulties, improve mothers’ confidence about the ability to breastfeed and enhance mothers’ knowledge on the normal process of lactation. Secondly, it is the role of policymakers to ensure implementation of Baby-Friendly Hospital Initiative (BFHI) guidelines in hospitals to meet the WHO’s global target of infants being exclusively breastfed until six months of age.

The impact of the Baby Friendly Hospital Initiative on neonatal hypoglycemia.

To assess Neonatal Intensive Care Unit (NICU) admissions for hypoglycemia after the introduction of the Baby Friendly Hospital Initiative (BFHI), followed by implementation of American Academy of Pediatrics recommended hypoglycemia guidelines. Retrospective review of NICU admissions for hypoglycemia. Eligible subjects were healthy infants >35 weeks gestation transferred to a NICU for hypoglycemia. Infants admitted with other pathologies were excluded. NICU admissions from 3 different 18-month epochs (1 = pre-BFHI; 2 = post-BFHI; 3 = post-BFHI+hypoglycemia guidelines) were compared. After implementation of BFHI there was a statistically significant increase in admissions for hypoglycemia (Epoch 2 = 1.23% vs Epoch 1 = 0.55%, p < 0.001). Followed by a decrease in admissions after the implementation of hypoglycemia guidelines (Epoch 2 = 1.23% vs Epoch 3 = 0.76%, p = 0.03). NICU admissions for hypoglycemia increased with the BFHI. Hypoglycemia guidelines decreased NICU admissions, but not to the pre-BFHI baseline.

Improved breastfeeding duration with Baby Friendly Hospital Initiative implementation in a diverse and underserved population.

Few studies have evaluated the impact of Baby Friendly Hospital Initiative (BFHI) implementation on underserved populations in the United States. We undertook this study in New Mexico, a large southwestern state with a diverse population and limited health care access. A quasi-experimental, retrospective cohort design was used to compare short-term breastfeeding duration between a pre-BFHI and a post-BFHI cohort. Among the post-BFHI cohort, logistic regression models were fitted to predict short-term breastfeeding duration from both individual and cumulative exposure to inpatient maternity care practices (Steps 4 to 9). Implementation of the BFHI and cumulative exposure to the Ten Steps increased short-term duration of any breastfeeding and exclusive breastfeeding at 2-6weeks postpartum. Exposure to all six of the inpatient Ten Steps increased the odds of any breastfeeding by 34 times and exclusive breastfeeding by 24 times. Exposure to Step 9 ("Give no pacifiers or artificial nipples") uniquely increased the likelihood of any breastfeeding at 2-6weeks postpartum by 5.7 times, whereas Step 6 ("Give infants no food or drink other than breastmilk") increased the rate of exclusive breastfeeding by 4.4 times at 2-6weeks postpartum. These findings demonstrate that the Baby Friendly Hospital Initiative can have a positive impact on breastfeeding among underserved populations.

Trends in Breastfeeding Interventions, Skin-to-Skin Care, and Sudden Infant Death in the First 6 Days after Birth

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 6days after birth. Survey data were used to determine a correlation between BFHI and deaths from SUID and asphyxia among infants <7days in the US and Massachusetts. Using data from the Centers for Disease Control and Prevention, implementation of BFHI was tracked from 2004-2016 and skin-to-skin care was tracked from 2007-2015. Using data from Centers for Disease Control and Prevention WONDER and the Massachusetts Department of Public Health, SUID and asphyxia were tracked from 2004-2016. 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 <7days 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, OR 0.85 (95% CI 0.77, 0.94). In 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: OR 0.32 (95% CI 0.13, 0.82), with 0 asphyxia deaths during the 13-year period. Increasing rates of breastfeeding initiatives and skin-to-skin care are temporally associated with decreasing SUID prevalence in the first 6days after birth in the US and Massachusetts.

Formula Feeding and Associated Factors among a Group of Egyptian Mothers.

BACKGROUND:Breastfeeding provides an unequalled way of infant nutrition, despite that, the rate of exclusive breastfeeding for the first 6 months in Egypt is only 13%, and the rates of artificial feeding are rising.AIM:The current study aimed to explore the reasons for the use of artificial feeding among mothers receiving subsidised milk from formula dispensing centres in Egypt, and to detect the reasons behind the use of a formula only for infant feeding rather than mixed breastfeeding and artificial feeding.METHODS:This exploratory cross-sectional study involved 197 mothers; who attended centres for dispensing subsidised artificial formula at primary health care facilities (PHC) in El-Fayom and Ismailia governorates via a purposive sampling technique. The study spanned over 6-months duration from June till December 2018.RESULTS:A statistically significant higher percentage of artificial feeding only was noticed in male infants (47.5% in the AF group only versus 28.7% in the mixed feeding group (p = 0.018), and infants aged 6-12 months (47.5% in the AF group only versus 28.7% in the mixed feeding group, p = 0.032). A statistically significant higher percentage of artificial feeding only was noticed among infants born to mothers who have general anaesthesia during labour (67.2% in the AF group only versus 41.9% in the mixed feeding group, p = 0.004), and among infants born to mothers who think that formula feeding is better (13.1% in the AF group only versus 0.7% in the mixed feeding group, or that formula has a similar quality to breast milk (6.6%% in the AF group only versus 4.4% in the mixed feeding group, p = 0.0004. The most common reasons for formula feeding reported by both groups were perceived breast milk insufficiency (60.9%), weak babies (50.3%), and doctors’ advice (37%). Previous negative breastfeeding experience and the need for own body privacy were the two reasons which differed statistically in both groups p = 0.004 and 0.008, respectively.CONCLUSION:Antenatal care education is essential to improve mothers’ knowledge and practice of breastfeeding. Baby-friendly hospital initiative implementation is essential to ensure early initiation and continuation of breastfeeding.

The impact of the UK Baby Friendly Initiative on maternal and infant health outcomes: A mixed-methods systematic review.

Global evidence demonstrates that adherence to the Baby Friendly Initiative (BFI) has a positive impact on multiple child health outcomes, including breastfeeding initiation and duration up to 1year post-partum. However, it is currently unclear whether these findings extend to specific countries with resource-rich environments. This mixed-methods systematic review aims 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 BFI-compliant care in the UK. Two authors independently extracted data including study design, participants, and results. There is no UK data available relating to wider maternal or infant health outcomes. Two quantitative studies indicate that Baby Friendly Hospital Initiative implementation has a positive impact on breastfeeding outcomes up to 1week post-partum but this is not sustained. There was also some evidence for the positive impact of individual steps of Baby Friendly Community Initiative (n=3) on breastfeeding up to 8weeks post-partum. Future work is needed to confirm whether BFI (hospital and community) is effective in supporting longer term breastfeeding and wider maternal and infant health outcomes in the UK. A meta-synthesis of five qualitative studies found that support from health professionals is highly influential to women's experiences of BFI-compliant care, but current delivery of BFI may promote unrealistic expectations of breastfeeding, not meet women's individual needs, and foster negative emotional experiences. These findings reinforce conclusions that the current approach to BFI needs to be situationally modified in resource-rich settings.

The revitalization and scale-up of the Baby-Friendly Hospital Initiative in Malawi.

The Baby‐Friendly Hospital Initiative (BFHI) has shown to strengthen health providers' skills in the provision of breastfeeding counselling and support, which have led to improvements in breastfeeding outcomes. In Malawi, where BFHI was introduced in 1993 but later languished due to losses in funding, the Maternal and Child Survival Program supported the Malawi Ministry of Health (MOH) in the revitalization and scale‐up of BFHI in 54 health facilities across all 28 districts of the country. This paper describes the revitalization and scale‐up process within the context of an integrated health project; successes, challenges, and lessons learned with BFHI implementation; 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 Southern region. Greater integration of BFHI into Malawi's health system is recommended, including improved preservice and in‐service trainings for health providers to include expanded BFHI content, increased country financial investments in BFHI, and integration of BFHI into national clinical guidelines, protocols, and nutrition and health policies.

Assessment of the Baby Friendly Hospital Initiative Implementation in the Eastern Mediterranean Region

The Baby-Friendly Hospital Initiative (BFHI) is a global program for promoting support and protection for breastfeeding. However, its impact on malnutrition, especially in countries of the Eastern Mediterranean region (EMR) that are facing the turmoil of conflict and emergencies, deserves further investigation. Having said that, this paper aims to discuss the status and challenges to BFHI implementation in the EMR countries. Data on BFHI implementation, breastfeeding practices, and nutritional status were collected from countries through structured questionnaires, personal interviews, and databases. The 22 countries of the EMR were categorized as follows: 8 countries in advanced nutrition transition stage (group I), 5 countries in early nutrition transition stage (group II), 4 countries with significant undernutrition (group III), and 5 countries in complex emergency (group IV). The challenges to BFHI implementation were discussed in relation to malnutrition. 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%). Countries with advanced nutrition transition had the highest implementation of BFHI but the lowest breastfeeding continuity rates. On 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). In countries with emergency states, breastfeeding continues to be the main source of nourishment. However, suboptimal breastfeeding practices prevail because of poor BFHI implementation which consequently leads to malnutrition. Political willpower and community-based initiatives are needed to promote breastfeeding and strengthen BFHI in the region.

Compliance With WHO/UNICEF BFHI Standards in Croatia After Implementation of the BFHI.

The primary goal of the Baby-Friendly Hospital Initiative (BFHI) is to create conditions in maternity facilities that enable women to initiate and sustain the practice of breastfeeding exclusively. Research aim: 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). Mothers of healthy, term infants ( N = 1,115) were recruited from the postnatal ward of the University Hospital of Split, Croatia, between February 2008 and July 2011 and followed for 12 months in a repeated-measures, prospective, longitudinal, three-group, nonequivalent, cohort study. Breastfeeding rates, hospital practices-including seven of the Ten Steps-and maternal sociodemographic data were collected. Parts of all seven Ten Steps that were assessed improved significantly post-BFHI. Step 3 ("antenatal education") showed the least improvement, whereas Step 7 ("rooming-in"; 2.6% pre-BFHI vs. 98.5% post-BFHI) and Step 9 ("no pacifiers/teats"; 21.8% pre-BFHI vs. 99.4% post-BFHI) showed the greatest improvement. Six months after Baby-Friendly designation, 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. Full implementation of the BFHI was associated with significant improvement in hospital practices and in-hospital, exclusive-breastfeeding rates, but it did not affect breastfeeding rates postdischarge, emphasizing the vital role of community support. Baby-Friendly Hospital Initiative standards declined rapidly post-hospital designation, indicating the need for regular monitoring and reassessment as well as ongoing, effective training for hospital staff.

Empowering women to breastfeed: Does the Baby Friendly Initiative make a difference?

The Baby-Friendly Hospital Initiative (BFI) is currently presented worldwide as the gold standard model of care for promoting and supporting breastfeeding. However, there is a lack of understanding about the ways in which health services, including the BFI, address the cultural change from a disembodied practice (formula feeding) to an embodied one (breastfeeding) in contexts where formula feeding is the norm. We used a qualitative case study methodology to compare the embodied experience of breastfeeding and the maternal experience of breastfeeding promotion and support services between mothers receiving care from institutions with low and high levels of BFI implementation in Québec, Canada. A total of 11 focus groups were conducted with mothers from six institutions-three with high and three with low levels of BFI implementation. We found the flexible approach to breastfeeding duration, characteristic of BFI services in our study, helped to avoid maternal guilt and shame; the 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. Findings have implications for the concept of habitus and the construction of the breastfeeding body; we suggest that habitus can change if agents are provided with discursive tools to negotiate this embodied change. Implications for BFI services include the need to implement the 10 steps in a flexible, family-centred way that focuses on empowering women rather than simply reaching outcomes.

A Multifaceted Approach to Revitalizing the Baby-Friendly Hospital Initiative in Croatia

The Baby-Friendly Hospital Initiative (BFHI) was launched in Croatia in 1993. By 1998, 15 of 34 maternity facilities were designated "Baby-Friendly." Introduction of hospital bags, violating the International Code of the Marketing of Breastmilk Substitutes, led to a standstill in the BFHI. The aim of this article is to describe the successful reintroduction of the BFHI in Croatia between 2007 and 2015. After hospital bags were abolished in 2007, UNICEF Croatia undertook an assessment of BFHI implementation. All maternity facilities were invited by UNICEF and the Ministry of Health to join the renewed BFHI. UNICEF materials were translated and training for trainers, assessors, coordinators, and hospital staff held. By June 2015, 30 of 32 (94%) maternity facilities, providing care to 89% of newborns, were Baby-Friendly. Nine maternity hospitals have been renovated and 2 new hospitals have been built. Exclusive 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). Fourteen "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. The BFHI provides an excellent opportunity for revitalizing breastfeeding protection, promotion, and support in all settings. Recognition and support of the BFHI by the Croatian government was crucial for implementing the BFHI, whereas the marketing practices of the breast milk substitutes industry are an ongoing challenge.