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Baby-Friendly Hospital Initiative (BFHI)

Core Elements

This section outlines the aspects of an intervention that are central to its theory and logic and that are thought to be responsible for the intervention’s effectiveness. Core elements are critical features of the intervention’s intent and design and should be kept intact when the intervention is implemented or adapted.

  1. Task Force Formation:  Two years prior to receiving Baby-Friendly status, Boston Medical Center (BMC) formed a Task Force to address low rates of breastfeeding among new mothers before discharge. The Task Force led efforts to implement and modify hospital policies and procedures in order to comply with the Baby-Friendly Hospital Initiative’s (BFHI) Ten Steps to Successful Breastfeeding (specifics of the Ten Steps are outlined below.)  The Task Force was co-chaired by the Chief of Ambulatory Pediatrics, the Director of the Newborn Nursery, and the Director of Nursing for Maternal and Child Services. The Task Force ultimately included 40 leaders and stakeholders from Pediatrics, Obstetrics and Gynecology, Midwifery, Family Medicine, Nursing, Postpartum, the Neonatal Intensive Care Unit, Prenatal Services, Nutritional Services, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and neighborhood health centers associated with BMCThe Task Force met once or twice per month.  Task Force members did not have protected time for these activities, and the process relied on a core of committed participants willing to devote time and energy the goal of becoming Baby-Friendly.
  2. Self Assessment: 200 randomly selected charts from 1995 were reviewed to determine breastfeeding rates.  Findings showed very low exclusive breastfeeding rates (6%) among new mothers before discharge, with only 30 percent of mothers giving more breast milk than formula while in the hospital.  Further findings of this self-appraisal were that BMC had no lactation staff or facilities, no lactation education programs for staff or patients, and no follow-up services for breastfeeding women.
  3. Organizational Breastfeeding Policy:  The Task Force developed a breastfeeding policy as part of the requirements of the Baby-Friendly designation.  The policy was adopted by the hospital and communicated to staff through trainings.  Education on the policy was incorporated into nursing competency requirements. 
  4. Publicity:  In order to increase the visibility of the BFHI at BMC, the Task Force initiated several efforts, including: opening a breastfeeding and breast milk pumping room in a highly visible location with a celebration and an announcement in the hospital newsletter; displaying signs listing the Ten Steps and artwork depicting breastfeeding women throughout the hospital; and having a notable female figure open the newly created Breastfeeding Center - the Lieutenant Governor of Massachusetts.
  5. Staff Education:  Guidelines from Baby-Friendly USA require that any pediatrician, obstetrician, family practice physician or advanced practice registered nurse that has staff privileges at a Baby-Friendly hospital or birth center receive education on the basics of breastfeeding management.  The amount and content of the training offered is tailored to the needs of the professionals.  At BMC, physician education was led by a pediatrician (also an International Board Certified Lactation Consultant) during grand rounds and monthly training sessions.  Nurse education was led by two pediatric nurse educators who created a breastfeeding competency as a requirement for all pediatric and obstetric nurses.  Other hospital personnel participated in “Reach and Teach” sessions to learn about the benefits of breastfeeding and to discuss ways to address breastfeeding issues specific to employee-patient interactions. 
  6. Education and Support for Mothers:  Lactation consultants taught weekly breastfeeding classes, and peer counselors were hired to work with mothers before and after discharge.  Peer counselors taught mothers of healthy newborns and neonatal intensive care patients about the benefits of breastfeeding and the importance of skin-to-skin contact between caregiver and infant.
  7. Paying for Formula:  As part of the requirements of the Baby-Friendly designation, a hospital cannot accept free formula from formula manufacturers.  This includes the formula-company sponsored gift bags that are distributed on postpartum floors in most hospitals.  Many United States hospitals find compliance with this step to be the greatest barrier to obtaining Baby-Friendly designation.  Paying for formula need not become the rate-limiting step in the process of becoming Baby-Friendly.  This issue is addressed in the detail in the next section, Resources Required, under the heading, Cost of Formula and Related Supplies.