Baby-Friendly Hospital Initiative Steps Research Articles

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.

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.

The Influence of the Baby-Friendly Hospital Initiative and Maternity Care Practices on Breastfeeding Outcomes.

The Baby-Friendly Hospital Initiative (BFHI) was launched in 1991 to promote breastfeeding through hospital policy. Researchers have reported breastfeeding improvements after hospitals became "Baby-Friendly." In Hong Kong, the first public hospital was designated as a Baby-Friendly Hospital in 2016. 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. This was a quasi-experimental interrupted time-series design. Two cohorts of mother-infant pairs (N = 2369) were recruited immediately postpartum from four public hospitals in Hong Kong and followed up prospectively. Comparisons were made in five of the BFHI steps experienced in both cohorts and the duration of any and exclusive breastfeeding. 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. Implementation of the BFHI was associated with improvements in breastfeeding practices and outcomes.

Beyond Statistics: Uncovering the Roots of Racial Disparities in Breastfeeding.

* Abbreviations: BFHI — : Baby-Friendly Hospital Initiative CDC — : Centers for Disease Control and Prevention IHS — : Indian Health Service Breastfeeding is for white women. This sentiment was expressed by several Black women featured in Chocolate Milk , an eye-opening documentary series that was shown during a 2-week virtual breastfeeding elective created for medical students and implemented amid the coronavirus disease 2019 pandemic.1 In addition to learning about proper latch techniques, effective positions, and the breastfeeding challenges that women face, our learning also revealed racial disparities in breastfeeding. As 2 medical students who identify as Black and Native American, we desired to dig deeper to better understand the roots of these disparities and the systemic changes we can advocate for within medicine. Racial disparities in breastfeeding are similar to those that persist in other facets of health, including infant mortality. According to the Centers for Disease Control and Prevention (CDC), only 25.6% of all US infants born in 2017 were exclusively breastfed through 6 months of age. Whereas the 6-month exclusive breastfeeding rate among white infants born in 2017 was above the national average at 28.7%, only 21.2% of Black infants born in the same year and 19.6% of Native American infants born in 2015 (there is a lack of reporting after 2015) were exclusively breastfed for the first 6 months of life.2 Given the known benefits of breastfeeding for both mother and infant and the increased risks of comorbid health conditions for these communities, there is much to learn about how … Address correspondence to Suet Kam Lam, MD, MPH, MS, Department of Pediatric Hospital Medicine, Cleveland Clinic, 9500 Euclid Ave, S1-20, Cleveland, OH 44195. E-mail: skl48{at}case.edu

Satisfaction with code implementation and Baby-friendly practices in the Eastern Mediterranean region: Health professional perspectives from 15 countries

Background: The revised ten steps of the baby-friendly hospital initiative (BFHI) in 2018 require breastfeeding protection through the implementation of the International Code of Marketing of breast-milk substitutes (The Code). Aim: The aim of the study was to assess the satisfaction of staff with the implementation of the global criteria of the revised “Ten steps” of BFHI in 15 Eastern Mediterranean region (EMR) countries. Methodology: Professionals representing Member States who registered to an EMR-WHO webinar meeting on monitoring BFHI were involved in giving feedback about the extent to which their workplace abides by the global criteria, Ten Steps including the Code. Feedback was also obtained about the status of adherence to the global criteria of steps 2, 3, 4, 5 6, and 9 using a rating scale (1–10). Countries were grouped into two groups: High income (HIC) and middle and low income (MIC and LIC). The results were statistically analyzed by country groups and by workplaces. Findings: 109 participants representing 15 countries responded. The respondents from HIC gave significantly higher satisfaction scores than MIC and LIC in relation to global criteria for the Code and steps 2, 3, 4, 5, 6, and 9 of the BFHI p&lt;0.05. There were significant correlations between all of the BFHI global criteria of the Code with staff training and competency skills, and some of the clinical practices included within the revised Ten Steps p&lt;0.05 from hospitals but not in the community. There were also significant differences between public and private hospitals in code, 1st h skin-to-skin contact (step 4), and counseling on risks of bottles and pacifiers (step 9). Conclusions: In the EMR implementation of the revised Ten Steps of BFHI particularly the Code, Step 4 and Step 9 need strengthening through monitoring, using the updated indicators, and competency training modules devised by the WHO and UNICEF in 2020.

Postpartum depressive symptoms following implementation of the 10 steps to successful breastfeeding program in Kinshasa, Democratic Republic of Congo: A cohort study.

Social support and relevant skills training can reduce the risk of postpartum depression (PPD) by reducing the impact of stressors. The 10-step program to encourage exclusive breastfeeding that forms the basis of the Baby-Friendly Hospital Initiative (BFHI) provides both, suggesting it may lessen depressive symptoms directly or by reducing difficulties associated with infant feeding. Our objective was to quantify the association of implementing Steps 1-9 or Steps 1-10 on postpartum depressive symptoms and test whether this association was mediated by breastfeeding difficulties. We used data from a breastfeeding promotion trial of all women who gave birth to a healthy singleton between May 24 and August 25, 2012 in 1 of the 6 facilities comparing different BFHI implementations (Steps 1-9, Steps 1-10) to the standard of care (SOC) randomized by facility in Kinshasa, Democratic Republic of Congo. Depressive symptoms, a non-registered trial outcome, was assessed at 14 weeks via the Edinburgh Postnatal Depression Scale (EPDS). Inverse probability weighting (IPW) was used to estimate the association of BFHI implementations on depressive symptoms and the controlled direct association through breastfeeding difficulties at 10 weeks postpartum. A total of 903 mother-infant pairs were included in the analysis. Most women enrolled had previously given birth (76%) and exclusively breastfed at 10 weeks (55%). The median age was 27 (interquartile range (IQR): 23, 32 years). The proportion of women reporting breastfeeding difficulties at week 10 was higher in both Steps 1-9 (75%) and Steps 1-10 (91%) relative to the SOC (67%). However, the number of reported difficulties was similar between Steps 1-9 (median: 2; IQR: 0, 3) and SOC (2; IQR: 0, 3), with slightly more in Steps 1-10 (2; IQR: 1, 3). The prevalence of symptoms consistent with probable depression (EPDS score >13) was 18% for SOC, 11% for Steps 1-9 (prevalence difference [PD] = -0.08; 95% confidence interval (CI): -0.14 to -0.01, p = 0.019), and 8% for Steps 1-10 (PD = -0.11, -0.16 to -0.05; p < 0.001). We found mediation by breastfeeding difficulties. In the presence of any difficulties, the PD was reduced for both Steps 1-9 (-0.15; 95% confidence level (CL): -0.25, -0.06; p < 0.01) and Steps 1-10 (-0.16; 95% CL: -0.25, -0.06; p < 0.01). If no breastfeeding difficulties occurred in the population, there was no difference in the prevalence of probable depression for Steps 1-9 (0.21; 95% CL: -0.24, 0.66; p = 0.365) and Steps 1-10 (-0.03; 95% CL: -0.19, 0.13; p = 0.735). However, a limitation of the study is that the results are based on 2 hospitals randomized to each group. In conclusion, in this cohort, the implementation of the BFHI steps was associated with a reduction in depressive symptoms in the groups implementing BFHI Steps 1-9 or 1-10 relative to the SOC, with the implementation of Steps 1-10 associated with the largest decrease. Specifically, the reduction in depressive symptoms was observed for women reporting breastfeeding difficulties. PPD has a negative impact on the mother, her partner, and the baby, with long-lasting consequences. This additional benefit of BFHI steps suggests that renewed effort to scale its implementation globally may be beneficial to mitigate the negative impacts of PPD on the mother, her partner, and the baby. ClinicalTrials.gov NCT01428232.

Knowledge and attitudes of Lebanese women towards Baby Friendly Hospital Initiative practices.

The World Health Organization and United Nations Children's Fund launched the Baby Friendly Hospital Initiative (BFHI) to encourage best infant breastfeeding practices immediately after birth. In Lebanon, few hospitals are currently accredited as Baby Friendly. 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. A cross-sectional survey of a random sample of healthy pregnant women from Lebanon's six governorates. The mean (SD) age of the participants (N = 517) was 28.6 (4.7) years. Most participants were unfamiliar with the terms Baby Friendly hospital (93.7%), skin-to-skin contact or kangaroo care (75%), or were inadequately instructed on how to initiate (54.2%) or continue (46.2%) breastfeeding. However, when provided with information about the benefits of BFHI practices, most mothers (> 90%) stated that they would deliver in Baby Friendly hospitals. About 68.4% of mothers refused to give donor human milk to their sick premature infants because of religious beliefs. Knowledge of Baby Friendly hospitals was significantly associated with university education (p = 0.029), higher monthly income (p = 0.042), and previous experiences of skin-to-skin contact (p<0.001), rooming in (p = 0.037), or breastfeeding support (p = 0.036). There is a need for national awareness campaigns that address both the numerous advantages of the BFHI practices and Lebanese women's knowledge gaps about these practices. Such knowledge will help scale up the implementation of BFHI practices in hospitals in Lebanon, thus increasing breastfeeding rates and positively impacting the health of infants and mothers.

The Baby-Friendly Hospital Initiative (BFHI): An Early Cross-Sectional Analysis of PRAMS Phase 8 Data on Hospital Practices and Breastfeeding Outcomes in Utah and Wyoming.

Breastfeeding has immediate and long-term benefits for both maternal and child health. This study examines the association between Baby-Friendly Hospital Initiative (BFHI) experiences and breastfeeding outcomes in the Mountain West region. A cross-sectional (retrospective secondary data analysis) was performed using the 2016 Pregnancy Risk Assessment Monitoring System (PRAMS) data. The participants were derived from a stratified random sample of 2,013 women living in Utah and Wyoming who recently had a live birth and who were surveyed on BFHI practices. The association between BFHI experiences and breastfeeding duration were assessed using crude and adjusted Poisson regression models, controlling for other BHFI experiences and maternal age, pre-pregnancy BMI, household income, smoking, alcohol, delivery method, and number of days spent in the hospital post delivery. 82.4% and 82.3% of women from Utah and Wyoming, respectively, reported breastfeeding for 2 months or longer. After controlling for other BFHI experiences and potential confounders, the one shared BFHI experience that was associated with breastfeeding for 2 months or longer vs less than 2 months was starting breastfeeding in the hospital (adjusted prevalence ratio [aPR]=1.49, 95% CI (1.12, 1.98) in Utah and aPR=2.03, 95% CI (1.13, 3.64) in Wyoming. Among women in Utah and Wyoming, only 5 of 7 BFHI steps were significant for breastfeeding duration in at least one state. There is substantial epidemiological support for health benefits to both mother and infant for exclusive breastfeeding to 6 months and prolonged breastfeeding until at least 1-year. Our findings suggest that women who initiate breastfeeding in the hospital may be more likely to breastfeed for a longer duration.

ASSOCIAÇÃO ENTRE OFERTA DE FÓRMULAS INFANTIS E CHUPETAS NA MATERNIDADE E AMAMENTAÇÃO NOS PRIMEIROS SEIS MESES DE VIDA

Introdução: Amamentação (AM) é base para a segurança alimentar e saúde. Deve ser promovida na maternidade por práticas como os passos 6 (não oferecer suplementos) e 9 (não oferecer bicos) da Iniciativa Hospital Amigo da Criança (IHAC). Objetivo: Avaliar o cumprimento dos passos 6 e 9 da IHAC e sua associação com a AM nos primeiros seis meses de idade. Metodologia: Coorte prospectiva em seis hospitais do município de São Paulo, sendo três Hospitais Amigos da Criança (HAC) e três não HAC. Mães foram entrevistadas na maternidade e por telefone aos 30 e 180 dias. Investigaram-se o cumprimento dos passos 6 e 9 e as práticas de AM. As associações foram analisadas por regressão logística ajustada para as variáveis de confusão determinadas pelo gráfico acíclico direcionado (DAG). Resultados: Amostra de 969 mães na primeira entrevista, 902 na segunda e 814 na terceira. Os passos 6 e 9 foram cumpridos nos dois grupos de hospitais. O não cumprimento do passo 6 reduziu o AME aos 30 dias (aOR=1,82; IC=1,19-2,77) e a AM aos 180 dias (aOR=1,79; IC=1,15-2,78). O descumprimento do passo 9 reduziu o AME aos 30 dias (aOR=2,33; IC=1,30-4,19). Conclusão: A chance do AME no primeiro mês foi reduzida pela oferta de fórmula infantil e chupeta na maternidade. Aos seis meses, a amamentação foi reduzida pela introdução de fórmula na maternidade. Os resultados reforçam a importância do cumprimento das disposições do Código Internacional de Comercialização de Substitutos do Leite Materno, propiciando um ambiente seguro que incentive a mulher a escolher amamentar.DOI: 10.12957/demetra.2019.43555

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.

Global initiatives to improve breastfeeding practices have focused on the Ten Steps to Successful Breastfeeding. 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. 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. Piecewise Poisson regression with generalized estimation equations to account for clustering by clinic was used to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI). 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). 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. NCT01428232.

Baby-friendly hospital practices are associated with duration of full breastfeeding in primiparous but not multiparous Iranian women.

There is evidence that the Baby-Friendly Hospital Initiative (BFHI) results in improved breastfeeding outcomes in Western countries, but little is known of its impact in Middle-Eastern countries. 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 followed-up prospectively for 6months. At baseline, mothers self-reported exposure to 7 of the BFHI Ten Steps to Successful Breastfeeding (Steps 3 to 9). Data on breastfeeding outcomes were collected at baseline, 1, 3, 4, and 6months postpartum. Cox regression analysis was conducted to determine the impact of individual and cumulative BFHI Steps on the duration of full breastfeeding, defined as the number of weeks since discharge that an infant received only breast milk and no complementary formula or food. Mothers reported experiencing on average 3.9 (SD 1.13, range 1 to 7) Steps, and only 28% of infants were fully breastfed at 6months. There was a protective inverse relationship for primiparous (p for trend=.022) but not multiparous mothers (p for trend=.069), between the number of Steps a woman was exposed to and the likelihood of her discontinuing full breastfeeding within 6months postpartum. Greater exposure to BFHI practices potentially could increase primiparous mothers' chances of fully breastfeeding to 6months. Continual monitoring of the BFHI Steps and repeated education of healthcare staff are required to ensure that Iranian mothers receive adequate breastfeeding support.

A Multicenter Survey for Monitoring the Baby-Friendly Initiative in 6 University Hospitals in Egypt (2017-2018): A Comparative Analysis

Introduction: University hospitals (UHs) face multiple challenges to achieve Baby friendly Hospital Initiative (BFHI) designation. Recently UNICEF has supported 6 UHs in Egypt to become Baby Friendly using the UNICEF/WHO BFHI monitoring tools. Aim: The aim of this study is to present and compare the monitoring activities that were carried out by 6 UH in Egypt for assessing BFHI after implementation. Methods: The six hospitals included in this study were AinShams UH (AsUH), Alexandria UH (AxUH), AlHussein (Azhar) UH (AzUH), Assiut UH (ATUH), Benha UH (BUH) and Cairo Kasr ElAini UH (KUH) using the monitoring tools of UNICEF/WHO BFHI. Four monitoring visits were conducted by each UH over the period of 3 months and involved interviews with mothers in maternity wards and NICUs, pregnant women in antenatal clinics and clinical staff in the service wards and observations. Data were collected and analyzed quantitatively into the UNICEF/WHO BFHI summary sheets of the tools. Results: Interviews totaled 915. Hospitals meeting BFHI global criteria were AinShams UH for steps 2, 6, 7 and AxUH for steps 1, 2, 3 and the Code. AzUH achieved steps 1 and 8 and the Code; BUH achieved steps 2 and 8; KUH steps 6 and 7. The lowest mean score was step 4 (16.87 ± 8.67) and the highest score was step 2 (61.68 ± 23.89). AxUH had the highest score in administrative activities, while AinShams UH had the highest score for clinical protocols and AzUH had the highest score for educational activities. Conclusions: A monitoring tool can be effective in achieving the global criteria for the Ten steps of BFHI by identifying gaps in program implementation.

Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review.

The Baby-friendly Hospital Initiative (BFHI) is a key component of the World Health Organization/United Nations Children's Fund Global Strategy for Infant and Young Child Feeding. The primary aim of this narrative systematic review was to examine the impact of BFHI implementation on breastfeeding and child health outcomes worldwide and in the United States. Experimental, quasi-experimental and observational studies were considered eligible for this review if they assessed breastfeeding outcomes and/or infant health outcomes for healthy, term infants born in a hospital or birthing center with full or partial implementation of BFHI steps. Of the 58 reports included in the systematic review, nine of them were published based on three randomized controlled trials, 19 followed quasi-experimental designs, 11 were prospective and 19 were cross-sectional or retrospective. Studies were conducted in 19 different countries located in South America, North America, Western Europe, Eastern Europe, South Asia, Eurasia and Sub-Saharan Africa. Adherence to the BFHI Ten Steps has a positive impact on short-term, medium-term and long-term breastfeeding (BF) outcomes. There 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). Community support (step 10) appears to be essential for sustaining breastfeeding impacts of BFHI in the longer term.

Ten Steps to Successful Breastfeeding programme to promote early initiation and exclusive breastfeeding in DR Congo: a cluster-randomised controlled trial.

Optimisation of breastfeeding practices could reduce high mortality rates in children younger than 5 years, but in DR Congo, despite near-universal breastfeeding initiation and nine of ten children still breastfeeding at 1 year of age, exclusivity remains a difficulty. We assessed the effect on breastfeeding outcomes of a short-cut implementation of a programme called the Ten Steps to Successful Breastfeeding, the key component of the Baby-Friendly Hospital Initiative (BFHI). We did a cluster-randomised controlled trial and randomly assigned health-care clinics in Kinshasa, DR Congo, to standard care (control group), BFHI steps 1-9 (steps 1-9 group), or BFHI steps 1-9 plus additional support during well-child visits (steps 1-10 group) with computer-generated random numbers used to assign matched pairs to study groups. Mothers at these clinics who had given birth to one healthy baby during enrolment, and who expressed their intentions of visiting a well-baby session at the same clinic, were eligible and received the treatment assigned to their clinic. Mother-infant pairs were excluded if the mothers intended to attend well-baby clinic visits at a different health facility, or to travel before the child was aged at least 6 months. Participants and independent interviewers were masked to group assignment (ie, they were recruited after randomisaion and training of the clinic staff and were not informed of the study scheme), but clinical staff were unmasked. BFHI steps 1-9 and 1-10 were given by health-care staff trained with the WHO/UNICEF BFHI course. The primary outcomes were breastfeeding initiation within 1 h of birth and exclusive breastfeeding at age 14 and 24 weeks, assessed at face-to-face interviews in the clinic. Analysis was by intention to treat. Prevalence ratios (PR) were adjusted for cluster effects and baseline characteristics. This trial is registered at ClinicalTrials.gov, number NCT01428232, and is closed to new participants. Between May 24, and Aug 25, 2012, we randomly assigned two eligible clinics to control, two to BFHI steps 1-9, and two to BFHI steps 1-10. We enrolled 975 eligible mother-infant pairs (304 in the control group, 363 in the steps 1-9 group, and 308 in the steps 1-10 group). 230 (76%) of infants in the control group, 263 (72%) in the steps 1-9 group, and 220 (71%) in the steps 1-10 group were breastfed within 1 h of birth; these results did not differ significantly between groups. Prevalence of exclusive breastfeeding at age 14 weeks was 89 (29%) in the control group, 237 (65%) in the steps 1-9 group (adjusted PR 2·20, 95% CI 1·73-2·77), and 129 (42%) in the steps 1-10 group (1·40, 1·13-1·74). At age 24 weeks, the prevalence of exclusive breastfeeding was 36 (12%) in the control group, 131 (36%) in the steps 1-9 group (3·50, 2·76-4·43), and 43 (14%) in the steps 1-10 group (1·31, 0·91-1·89). In the setting of health-care clinics in DR Congo with a high proportion of mothers initiating breastfeeding, implementation of basic training in BFHI steps 1-9 had no additional effect on initiation of breastfeeding but significantly increased exclusive breastfeeding at 6 months of age. Additional support based on the same training materials and locally available breastfeeding support materials, offered during well-child visits (ie, step 10) did not enhance this effect, and might have actually lessened it.

Awareness about "Ten Steps for Successful Breastfeeding" among Medical and Nursing Students.

Background:Baby-friendly Hospital Initiative (BFHI) is a vital intervention supported by World Health Organization and UNICEF to reduce infant mortality and has been included as a part of the curriculum in nursing and medical courses. 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.Methods:A descriptive cross sectional study was carried out among the nursing (4th year) and medical students (3rd year MBBS) about ten steps of BFHI by a pretested and predesigned questionnaire. After ethical clearance, information was collected about their awareness and correct understanding concerning ten steps.Results:A total 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.Conclusions:BFHI is one of the successful international efforts undertaken to promote, protect and support breast feeding. Acquiring knowledge about the same by medical and nursing students is most crucial tool for better practices by them in the future. Continued medical education, workshops and seminars by lactation specialists in addition to the regular teaching about BFHI as part of the curriculum may be considered to ensure and update their knowledge about BFHI.

Application of the Baby Friendly Hospital Initiative to Neonatal Care: Suggestions by Swedish Mothers of Very Preterm Infants

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. Thirteen mothers were interviewed 2 to 6 months after their infants' discharge from the hospital. The interviews generated 13 steps, which partly agree with the BFHI steps. The new steps address respect for mothers' individual decisions about breastfeeding, education of staff in specific knowledge and skills, antenatal information about lactation in the event of preterm birth, skin-to-skin (kangaroo mother) care, breast milk expression, early introduction of breastfeeding, facilitation of mothers' 24-hour presence in the hospital, preference for mother's own milk, semi-demand feeding before transition to demand breastfeeding, special benefits of pacifier sucking, alternative strategies for reduction of supplementation, use of bottle-feeding when indicated, a family-centered and supportive physical environment, support of the father's presence, and early transfer of infants' care to parents.

Evidence based breast-feeding promotion: the Baby-Friendly Hospital Initiative.

The Baby-Friendly Hospital Initiative (BFHI) is the translational tool developed by WHO and UNICEF to promote breast-feeding (BF) in maternity wards worldwide. BFHI was officially launched in the 1980s based on a "common sense" approach. Since then, research conducted in Latin America has shown that BFHI is highly cost-effective. BF trends over the past 2 decades strongly suggest that BFHI has had a global impact on BF outcomes. The 10th step of BFHI related to community-based BF promotion is one of the most challenging ones to address. Randomized controlled trials conducted in the Americas, Asia, and sub-Saharan Africa indicate that peer counseling is a very efficacious tool for increasing EBF rates. Low-cost rapid-response monitoring systems are needed to monitor the proper implementation and administration of BFHI steps following an evidence-based approach. This approach is essential for reenergizing the BFHI worldwide.