What is the Baby Friendly Hospital Initiative?

by Donna Walls, RN, BSN, IBCLC, ANLC

The Baby Friendly Hospital Initiative was developed and implemented by the World Health Organization and UNICEF in 1991. These organizations recognized the importance of breastfeeding to human health as well as the influence the formula industry marketing to parents making the decision of how to feed their newborns. There was also recognition that in many countries hospitals and birth centers continued practices that undermined breastfeeding success.

“The Baby Friendly Hospital Initiative (BFHI) assists hospitals in giving mothers the information, confidence, and skills necessary to successfully initiate and continue breastfeeding their babies and gives special recognition to hospitals that have done so.  In cases where patients have a medical indication or have made an informed decision to use formula, the safe preparation and feeding of formula is provided to mothers.” (WHO)

The WHO and UNICEF administer the BFHI program internationally and work with the national authority in each country which confers the Baby-Friendly® designation in their nation. More than 20,000 maternity facilities in 150 countries around the world have earned the Baby-Friendly designation. In the United States, the BFHI authority is Baby Friendly USA. In the US, the number of hospitals achieving the Baby Friendly designation is rising with more than 600 hospitals having been designated representing more than 28% of hospitals in the US. The foundation of this initiative is based on the evidence-based practices shown to enable new mothers to optimally breastfeed in the first days after birth. The Ten Steps to Successful Breastfeeding are:

  1. Have a breastfeeding policy which is routinely communicated to all staff
  2. Train all health care staff to implement these policies
  3. Inform all pregnant women about benefits and management of breastfeeding
  4. Initiate breastfeeding within ½-1 hour after birth
  5. Show Mothers how to maintain lactation if they are separated from their babies
  6. Give newborns no supplements unless medically indicated
  7. Practice rooming-in, allow Mothers and babies to remain together
  8. Encourage breastfeeding on demand
  9. Give no artificial teats or pacifiers
  10. Foster the establishment of BF support groups and refer Mothers to them on discharge from the hospital

As the number of hospitals being designated as Baby Friendly rises, misinformation persists concerning the designation. One rumor is that formula feeding families are “not welcomed” or “made to feel guilty” if not breastfeeding. In reality, just the opposite is true. Although breastfeeding benefits and management are discussed, Baby Friendly hospitals require that formula preparation instructions be given on an individual basis to those families who have chosen to formula feed. Practices such as skin to skin care, rooming-in and responsive cue feeding benefits all babies, not just breastfeeding newborns. BFHI also supports the International Code of Marketing of Breast-Milk Substitutes. The major tenants of “the Code” are:

  1. No advertising of breast-milk substitutes to families.
  2. No gifts, free samples or supplies to healthcare providers.
  3. No promotion of products through health care facilities, including no free or low-cost formula.
  4. No contact between marketing personnel and mothers.
  5. No words or pictures idealizing artificial feeding, including pictures of infants, on the labels or product.
  6. Information to health workers should be scientific and factual only.
  7. All information on artificial feeding, including labels, should explain the benefits of breastfeeding and the costs and hazards associated with artificial feeding.
  8. Unsuitable products should not be promoted for babies.
  9. All products should be of high quality and take account of the climate and storage conditions of the country where they are used.

In 2017, WHO and UNICEF began an updating process to the Ten Steps to Successful Breastfeeding incorporating recent research and recommendations from many global maternal-child health advocates. These are the updated Steps:

Ten steps to successful breastfeeding (revised 2018)

WHO and UNICEF launched the Baby-friendly Hospital Initiative (BFHI) to help motivate facilities providing maternity and newborn services worldwide to implement the Ten Steps to Successful Breastfeeding. The Ten Steps summarize a package of policies and procedures that facilities providing maternity and newborn services which support breastfeeding. WHO has called upon all facilities providing maternity and newborn services worldwide to implement the Ten Steps.

Ten steps to successful breastfeeding

Critical management procedures 1a. Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions. 1b. Have a written infant feeding policy that is routinely communicated to staff and parents. 1c. Establish ongoing monitoring and data-management systems.

  1. Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding.

Key clinical practices

  1. Discuss the importance and management of breastfeeding with pregnant women and their families.
  2. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.
  3. Support mothers to initiate and maintain breastfeeding and manage common difficulties.
  4. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.
  5. Enable mothers and their infants to remain together and to practise rooming-in 24 hours a day.
  6. Support mothers to recognize and respond to their infants’ cues for feeding.
  7. Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.
  8. Coordinate discharge so that parents and their infants have timely access to ongoing support and care.

There is substantial evidence that implementing the Ten Steps significantly improves breastfeeding rates. A systematic review of 58 studies on maternity and newborn care published in 2016 demonstrated clearly that adherence to the Ten Steps impacts early initiation of breastfeeding immediately after birth, exclusive breastfeeding and total duration of breastfeeding.

Other key components of the revisions:
  1. Stresses the importance of exclusive breastfeeding for 6 months to provide the nurturing, nutrients and energy needed for physical and neurological growth and development
  2. Stresses the need for all Ten Steps to be implemented as a package in order to attain an optimal impact on breastfeeding
  3. Provides updated guidance for the safe implementation of practices and monitoring of patients. Reminds health care providers of the importance of individualized attention and care.
  4. Describes the importance of mother-friendly birth practices and the impact of birth practices on breastfeeding. Stresses the importance of healthcare professionals being knowledgeable about those practices and their responsibility for educating mothers.  Refers them to other WHO guidelines for more details on the specific practices.
  5. Reinforces the role of facilities providing maternity and newborn services of identifying appropriate community resources for continued and consistent breastfeeding support that is culturally and socially sensitive to the needs of families. Reminds facilities they have a responsibility to engage with the surrounding community to enhance such resources.

In November of 2019, the Journal of Pediatrics published a research study demonstrating that those hospitals and birth centers that have designated as Baby Friendly show lower rates of newborn mortality in the first 6 days postpartum. Dr. Melissa Bartick, lead author of the study and internist at Cambridge Health Alliance and Assistant Professor of Medicine at Harvard Medical School, said: “These data come as welcome news and should reassure us that these initiatives are not resulting in any increase in infant deaths – that in fact, just the opposite is true.” Baby Friendly USA is working to ensure that a provision is included in a resolution for the upcoming World Health Assembly to request the Director General of WHO to work in collaboration with UNICEF to develop tools for training, monitoring, and advocacy on the Baby-Friendly Hospital Initiative to assist Member States with implementation. Baby Friendly USA is also reviewing the WHO revisions to “align the US BFHI with the 2018 WHO BFHI Implementation Guidance”.  These interim guidelines allows BFUSA to implement the more flexible standards immediately and then work to finish and release the completely revised US guidelines that fully align with the 2018 WHO BFHI Implementation Guidance. The following Interim Guidelines and Evaluation Criteria will be effective at all on-site assessments taking place from February 1, 2020  – December 31, 2022. Step 2 Added language to criterion 2.1.3: The designated health care professional(s) will provide documentation that training for breastfeeding and parent teaching for formula preparation and feeding is provided for all health care staff caring for mothers, infants and/or young children and that new staff are oriented on arrival and scheduled for the completion of training within 6 months (for example, by providing a list of new staff who are scheduled for training).  Provides clarification that all policy orientation and new staff training are to be completed by 6 months after hire date. Step 3 Revised criterion 3.2.2 to read: At least 80% of pregnant women will report that a staff member at the affiliated prenatal services entered into a conversation with them on the necessary topics, either one-on-one or in small groups, or by following up to education provided through another learning mode [i.e. videos, podcasts, texts] based on their specific needs. Provides additional language to use of technologies and follow-up conversations. Step 7 Revised guideline 7.1 to read: Rooming-in 24 hours a day is the expected standard for mother infant care for healthy term infants, regardless of feeding decision. The medical and nursing staff conduct newborn procedures at the mother’s bedside whenever possible and avoid frequent separations or absences of the newborn from the mother for more than a total of one hour in a 24-hour period. When a mother requests that her infant be cared for in the nursery, the health care staff should sensitively engage her in a conversation to learn more about her understanding of the importance of rooming in and the reasons for the request. Staff should work to resolve any medical reasons, safety-related reasons, or maternal concerns.  If the mother still requests or if it is determined that the infant is best cared for in the nursery, the process and informed decision should be documented.  The mother should be provided access to feed her infant at any time and with a plan that she will be reunited with her infant as soon as her infant displays feeding cues. Section Change Additional information Step 7 Added language to criterion 7.1.2 to include: 7.1.2  Criterion for evaluation: Of randomly selected mothers with healthy term infants, at least 80% will report that since they came to their room after birth (or since they were able to respond to their infants in the case of cesarean birth), their infants have stayed with them in the same room day and night except for up to one hour per 24-hour period, unless they report the following:  • medically justifiable reason for a longer separation or, • safety-related reason for a longer separation or, • an informed decision (maternal request for separation). Step 7 New criterion 7.1.3 added to clarify the required documentation regarding reasons for separation: 7.1.3 Criterion for evaluation: Of mothers and infants who have been separated for more than a total of one hour in a 24-hour period, at least 80% will have the medically justifiable, safety-related reasons for the separation, or evidence of parental counseling (in the event of parental choice) clearly documented in the medical record. Step 7 Criterion 7.1.4 Criterion for evaluation: Observations in the postpartum unit and any well-baby observation areas and discussions with mothers and staff confirm that at least 80% of the mothers and infants are rooming-in or have documented medically justifiable reasons, safety-related reasons, or informed maternal decision for separation. For more information and updating, find the most current information on BabyFriendlyUSA.org. How can we support breastfeeding and the Baby Friendly Hospital Initiative? All caregivers, educators, doulas, midwives, bedside caregivers and physicians can play an important  role in supporting the Baby Friendly Hospital Initiative. Include information on basic breastfeeding management and resources for support in the community in classes or during prenatal care visits. Offer education which is culturally appropriate and include time for discussion whenever possible. Provide information on the Baby Friendly Ten Steps to Successful Breastfeeding and offer resources for finding Baby Friendly Hospitals in their area.


https://www.who.int/nutrition/bfhi/ten-steps/en/ https://www.babyfriendlyusa.org/wp-content/uploads/2019/11/SummaryChanges-InterimGEC-191107.pdf World Health Organization, United Nations Children’s Fund, Wellstart International. The Baby-friendly Hospital Initiative: monitoring and reassessment: tools to sustain progress. Geneva: World Health Organization; 1991 (WHO/NHD/99.2; http://apps.who.int/iris/handle/10665/65380, accessed 7 March 2018). Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475–90. doi:10.1016/S0140-6736(15)01024-7. Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. Geneva: World Health Organization; 2017 (http://apps.who.int/iris/bitstream/10665/259386/1/9789241550086-eng.pdf?ua=1, accessed 7 March 2018). Standards for improving quality of maternal and newborn care in health facilities. Geneva: World Health Organization; 2016 (http://apps.who.int/iris/bitstream/10665/249155/1/9789241511216-eng.pdf?ua=1, accessed 7 March 2018). WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018 (http://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf, accessed 7 March 2018). United Nations Children’s Fund. UNICEF data: monitoring the situation of children and women. Access the data: infant and young child feeding (http://data.unicef.org/topic/nutrition/infant-and-young-childfeeding/, accessed 7 March 2018). Smith ER, Hurt L, Chowdhury R, Sinha B, Fawzi W, Edmond KM et al. Delayed breastfeeding initiation and infant survival: a systematic review and meta-analysis. PLoS One. 2017;12(7):e0180722. doi:10.1371/journal.pone.0180722. 

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