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Baby-Friendly Hospital Initiative (BFHI)

Evidence Summary

Underlying Theory:  The Baby-Friendly Hospital Initiative (BFHI) at Boston Medical Center (BMC) uses constructs of Social Cognitive Theory including: environment, situation, behavioral capability, expectations, observational learning, self-efficacy, behavioral capability, and reciprocal determinism.

Strategies Used1The BFHI at BMC includes multiple evidence-based breastfeeding strategies that have been adapted to the hospital setting, including:

  •  Education for mothers about breastfeeding during prenatal and intrapartum periods by providing breastfeeding classes and resources.
  • Maternity care practices in the hospital setting through written policies and staff training that: promote early breastfeeding initiation immediately following birth, prevent separation of mother and infant, restrict the availability of supplements and pacifiers, provide rooms that accommodate mothers and babies, and ensure follow-up for breastfeeding mothers after discharge.
  • Professional support for breastfeeding by health professionals There are multiple ways in which BMC maternity staff supports breastfeeding mothers: 1) Nurses and patient care assistants are specially trained to provide hands-on lactation support at the bedside. 2) Nurses provide breastfeeding education to families and are the front line in encouraging mothers to continue exclusive breastfeeding.  3) Lactation consultants, all of whom are RNs and hold the additional credential of International Board Certified Lactation Consultant (IBCLC), provide specialized evaluation and management of lactation problems, including failure to latch, poor supply, excessive weight loss, nipple pain, and tongue tie.
  • Peer support for breastfeeding Peer counselors play a critical role in troubleshooting, educating, and offering hands-on support to breastfeeding mothers.  Not every breastfeeding mother will encounter difficulties that require the services of a lactation consultant.  Many common issues such as perceived inadequate milk supply, positioning, infant feeding cues, and how to use a breast pump, can be addressed by peer counselors.  These early interventions can often prevent breastfeeding problems before they occur.  Peer counselors are also an invaluable source of support and encouragement to breastfeeding mothers, and bring a unique perspective as peers rather than medical providers.

Research Findings and Evaluation Outcomes:

TheBaby-FriendlyHospitalinitiative (BFHI) was reviewed as a research-tested intervention in the context of its implementation at Boston Medical Center (BMC).  Three peer reviewed articles examined the effect of Baby-Friendly practices on: breastfeeding initiation and exclusivity rates(Philipp et al, 2001); sustained breastfeeding initiation rates(Philipp et al, 2003); and breastfeeding duration rates at six months of age (Merewood et al, 2007).

Intervention Effect (initiation and exclusivity rates): Breastfeeding initiation rates were compared at BMC before (1995), during (1998), and after (1999) the Baby-Friendly policies were implemented.  Breastfeeding initiation was defined as an infant receiving any amount of breast milk while in the hospital after birth.  Random medical chart review of 200 records showed that the breastfeeding initiation rates increased from 58% (1995) to 77.5% (1998) to 86.5% (1999).  Infants exclusively breastfed, defined as receiving no formula while in the hospital, increased among US born, black mothers in this population from 34% (1995) to 64% (1998) to 74% (1999).

Intervention Effect (sustained initiation rates): Breastfeeding initiation rates were again measured in 2000 and 2001 and compared with initiation rates in 1999 (the year that BMC received Baby-Friendly designation) to determine if the increased rates could be sustained over time.  Breastfeeding initiation rates remained high: 87% (1999), 82% (2000), and 87% (2001). 

Intervention Effect (duration rates):  A random selection of 350 medical records of infants born in 2003 at BMC were reviewed, and of the eligible infants who returned for the six-month follow-up visit, 37.1% were still breastfeeding at six months of age.  Among a predominantly low-income, black population, breastfeeding rates at 6 months were comparable to the overall US population. 



1 A full description of the intervention strategies used can be found here with references to the sources of evidence to support the strategies.