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Connecticut Breastfeeding Initiative


The Connecticut Department of Public Health administered the project, provided financial oversight, purchased materials used in the project, and reported to the project funder (CDC). The Connecticut Breastfeeding Coalition (CBC) conceived of and developed the project proposal for the CBI. The CBC’s role throughout the project was to contract with and provide oversight for the Baby-Friendly consultant and for an administrative assistant who implemented the day-to-day activities of the CBI, including: creating a hospital toolkit, conducting needs assessments, planning trainings, and providing technical assistance to hospitals. 

The CBI’s approach to planning and implementing a state-level system to support the adoption of the Baby-Friendly Hospitals intervention is outlined below.

Planning and Preparing

  • Engage partners with varying strengths to share the project workload, including administration/oversight, day-to-day activities, and marketing. Create a comprehensive Communication Plan to clearly define expectations for all stakeholders about project implementation, dissemination and sustainability.
  • Hire or work with a Baby-Friendly expert to plan the delivery of training. To meet the needs of various organizations, consider multiple training formats and allow hospitals to send staff to train at multiple locations on multiple dates. This flexibility makes it possible for facilities to maintain staffing levels within the facility while other staff participate in training. Some facilities found that training key staff to subsequently train coworkers (train-the-trainer model) or using online modules fit their needs better. Also consider hiring an administrative assistant to schedule and take care of training logistics.
  • Hire a Baby-Friendly expert to provide technical assistance. Consider the different types of consulting hours needed, such as for individuals and groups, rather than individual hospital consulting hours alone. Communicate quarterly the allotment of consultation hours that hospitals have used and have remaining.
  • Create Frequently Asked Question sheets (FAQs) for hospitals wanting to participate in the project informing them about the Baby-Friendly Hospital Initiative, promoting project resources and limitations, and setting clear expectations.
  • To drive clear expectations, timely progress, and/or recognition of the need for additional support, create a timeline and identify benchmarks for all stakeholders and participating hospitals.
  • Plan CBI training content. Ensure coverage of the 15 lessons required for Step 2 of the Ten Steps to Successful Breastfeeding. Incorporate adult learning theory and strategies to manage change, both of which help build staff commitment to the initiative and empower champions to drive cultural change in their organizations. Provide participating hospitals anticipatory guidance for answering questions and addressing issues related to time, staffing and financial implications of the training component of the project.
  • Create a toolkit of resources for participating hospitals. Resources can include Baby-Friendly USA tools and sample documents from a maternity care facility that achieved Baby-Friendly designation. Note: Many of the Baby-Friendly tools are proprietary and only available to hospitals that have paid the fees and are progressing down the 4-D pathway. Because of this, hospitals not pursuing designation may need to use, develop, and share other tools from a different source.
  • Foster relationships among participating hospitals by creating opportunities for peer support. Offer conference calls and in-person workshops to brainstorm solutions to challenges and to share best practices, resources and successes.
  • Engage Baby-Friendly USA as an active partner by 1) establishing open communication and 2) encouraging participating hospitals to partner and communicate with Baby-Friendly USA after the project has ended.
  • Plan for evaluation from the beginning of the project. The CBI recommends incorporating pre-testing of hospital staff, including perceptions, attitudes, and beliefs about Baby-Friendly practices, and pre/post measurement of didactic training.
  • Incorporate sustainability planning from the beginning of the project. Consider a sustainability plan as a living document that will drive quality improvement throughout project implementation and dissemination.
  • Brand all project materials and resources.

Hospital Recruitment and Selection Process

  • Host a presentation to explain the project, dispel myths about the Baby-Friendly Hospital Initiative, and generate interest in participation among hospitals. (CBC hosted a dinner presentation.)
  • Create and distribute a short assessment form to maternity hospitals in the state. The form should ask about the level of buy-in and support from hospital administration for the project. Other questions should indicate the hospital’s commitment to the process, for example: “Has your facility considered a Baby-Friendly designation in the past? Please describe your obstacles.”
  • Out of the hospitals that complete the form, use the answers to the assessment questions and data on public pay births to select participating hospitals. Integrating data on public pay births into the selection process increases the likelihood that the project will reach women at greatest risk of not breastfeeding.

Training and Technical Assistance

Engage a staff person or a consultant with expertise in the Baby-Friendly Hospital Initiative. For the CBI, this person played a key role in the delivery of training and technical assistance and the development of some materials disseminated to participating hospitals. This person’s prior experience with the Baby-Friendly model, as the team leader in a hospital recently designated as Baby-Friendly, proved beneficial to the participating hospitals.

Technical assistance:

  • Allot consulting hours to each hospital. CBI initially allotted 40 hours per hospital for one-on-one coaching, trouble-shooting, etc. With Baby-Friendly USA’s transition from the Certificate of Intent process to the 4-D Pathway, it was discovered that a significant portion of the consultant’s time focused on tasks benefitting all participating hospitals equally. Additionally, bringing hospitals together under the direction of the consultant resulted in both support and friendly competition among peers. The most effective uses of the consultant’s time were standing telephone calls/meetings with all the hospitals, scheduled visits, and telephone and e-mail contact as needed.
  • Once hospitals were accepted into the project, they received a welcome letter from the consultant outlining project components. Additionally, key contacts from the 10 project hospitals received a toolkit with materials to assist in self-assessment. To determine where an institution stood on implementation of each of the Ten Steps, completing the Self-Assessment from the Discovery Phase of the 4-D Pathway was required. The consultant tailored technical assistance to each hospital based on the Self-Assessment results.
  • Conduct a mock survey with each hospital to simulate the Baby-Friendly USA assessment process and assess the hospitals’ progress in achieving each of the Ten Steps. The CBI consultant used the Baby-Friendly USA audit tools from the Dissemination phase to develop the mock survey.
  • Coordinate and conduct a sustainability conference for hospitals to identify and address barriers to sustainability and plan for how to continue on the Baby-Friendly pathway. The CBI sustainability conference identified approaches to a variety of sustainability domains; those most frequently identified as needing attention and coordinated planning were financial stability, partnerships and communication.
  • Coordinate and conduct a lessons learned teleconference for project participants, as well as for other facilities/organizations considering BFHI either at the facility level or as a public health initiative.


  • Work with the Baby-Friendly expert to coordinate in-person training to participating hospitals. Among CBI participating hospitals, not all staff were able to attend, and some staff/hospitals opted to meet the training requirement in other ways, through a train-the-trainer model or using online training. The consultant was key in identifying other training options.

Note: Hospitals and other maternity facilities may meet the training requirement in a variety of ways. Two documents regarding training options are provided in the intervention materials section.

Financial assistance

The cost to a hospital of going through the 4-D Pathway and applying for designation can be a barrier. The financial assistance component of the CBI removed the cost barrier and provided an incentive to work towards designation. The assistance was a crucial part of the CBI’s success and was extremely valuable to participating hospitals. The CBI provided the following financial assistance to each hospital:

  • $750 for dissemination of staff and patient education materials
  • $2000 for Baby-Friendly USA maternity hospital fees to enter the Dissemination Phase of the 4-D Pathway. As there is no cost for the Discovery Phase of the Pathway, CBI required participating hospitals to pay the fee to enter the Development Phase, thus demonstrating commitment from hospital administration prior to receiving CBI financial support.
  • $2000 for any additional fees as hospitals progress through the 4-D Pathway and beyond: Designation Phase includes fees for onsite assessment by Baby-Friendly USA or maintenance fees after official designation (these funds were unexpected and added at the end of the grant period).

Monitoring and evaluation

The CBI staff found it valuable to conduct an externally-led evaluation to collect qualitative and quantitative data from the participating hospitals to drive program improvement and identify promising practices for future initiatives. The CBI used a database to collect significant process evaluation data, and contracted with an outside evaluation firm to analyze the data, conduct interviews with multidisciplinary hospital breastfeeding committees, and assess effectiveness of the training via an online maternity staff survey.

  • The database was used to collect:
    • Number of hours the consultant worked with each hospital
    • Additional consultant activities, and
    • Hospitals’ progress in the 4-D pathway.
  • Interviews were conducted with the multidisciplinary breastfeeding committee to: 1) identify the strategies specific to the CBI that facilities were successful/unsuccessful in implementing; 2) identify strengths and areas in need of improvement for the CBI’s technical assistance (particularly the use of the consultation hours); and 3) to collect lessons learned and success stories.
  • A one-time retrospective survey was distributed electronically to maternity staff to assess changes to practice after the training, changes in knowledge and beliefs about Baby-Friendly practices, and successes experienced as a result of implementing the Steps. (See the Evidence Summary for more detail on the results and methods.) Note: The CBI recommends to others working on similar projects the use of a pre/post survey in place of a one-time retrospective survey.

The evaluation report completed by the contractor documents results and lessons learned that may be useful if this systems approach to Baby-Friendly Hospitals is continued, expanded, or adopted elsewhere. The CBI staff placed a high value on collecting the lessons learned from the project in order to improve this work in the future.

Keys to Success

  • Hospital administration support of the policy changes and financial commitment necessary to implement the Ten Steps to Successful Breastfeeding (the reverse could be a barrier).
  • Ensuring the involvement of staff or a consultant who has BFHI expertise.
  • Providing opportunities for hospitals to learn from each other.
  • The existence of administrative capacity and engagement around breastfeeding at the state level (such as within the State Department of Public Health and State Breastfeeding Coalition).
  • Using existing Baby-Friendly materials. (A hospital that is not working towards designation but still attempting to implement some of the Steps may not be able to use Baby-Friendly USA materials as most are proprietary.)
  • Integrating evaluation and monitoring into the implementation of the CBI.
  • Strengthening existing partnerships and building new ones to ensure capacity to address each component of the project design.

Barriers to Implementation

  • Hospital policy changes are often needed to allow adoption of maternity care practices in keeping with the Ten Steps to Successful Breastfeeding (such as rooming-in, skin-to-skin, avoidance of pacifiers and formula supplementation without medical need). These policy changes have financial implications, as well as implications for staff practice.
  • Preconceived views of the Baby-Friendly approach and/or resistance to the approach by maternity staff and/or hospital administration.
  • Process and perception of cost of purchasing infant formula.
  • Advertising capacity of formula companies and misunderstanding by both maternity staff and patients about the true impact of free gifts from formula companies on breastfeeding success.
  • Staff training (including ongoing training over time) can be a logistical challenge for hospitals.