Assessment of the impact of implementing the Baby-Friendly Hospital Initiative. Effects of exclusive breastfeeding for four versus six months on maternal nutritional status and infant motor development: results of two randomized trials in Honduras. Do Baby-Friendly Hospitals Influence Breastfeeding Duration on a National Level? Breastfeeding promotion in non‐UNICEF‐certified hospitals and long‐term breastfeeding success in Germany Breast milk and neonatal necrotising enterocolitis Effect on rates of breast feeding of training for the Baby Friendly Hospital Initiative Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus. Evaluation of a lactation intervention program to encourage breastfeeding: a longitudinal study. Baby-friendly hospital initiative improves breastfeeding initiation rates in a US hospital setting. Protective effect of breastfeeding against urinary tract infection. Comparison of the effect of two systems for the promotion of exclusive breastfeeding Evaluation of the impact of the baby-friendly hospital initiative on rates of breastfeeding. The effectiveness of a hospital-based program to promote exclusive breast-feeding among low-income women in Brazil.
OBJECTIVE To evaluate the impact of the Baby-Friendly Hospital Initiative on the breastfeeding practice s of mothers from the urban area of Montes Claros , MG , Brazil . METHODS A comparative analysis was performed of two cross-sectional breastfeeding indicator studies with r and omized sample s of children under 2 years of age . One study was carried out before and the other after the Baby-Friendly Hospital Initiative had been implemented throughout all public pregnancy and childbirth care services in the city . Kaplan-Meyer survival curves were constructed for different breastfeeding patterns . Log rank testing was used to calculate the level of significance of differences between curves for before and after the Initiative . RESULTS The survival curves demonstrate that breastfeeding rates increased during the study period . The log rank test detected significance for increases in all patterns of breastfeeding ( p < 0.000 ) . Median overall breastfeeding duration increased from 8.9 to 11.6 months and median duration of exclusive breastfeeding rose from 27 days to 3.5 months . CONCLUSIONS Implementation of the Baby-Friendly Hospital Initiative in all public maternity units in Montes Claros significantly increased breastfeeding rates in the city . Since the ideal state of affairs has not yet been reached , further strategies must be implemented to promote and support breastfeeding practice To examine whether the duration of exclusive breastfeeding affects maternal nutrition or infant motor development , we examined data from two studies in Honduras : the first with 141 infants of low-income primiparous women and the second with 119 term , low birth weight infants . In both studies , infants were exclusively breastfed for 4 mo and then r and omly assigned to continue exclusive breastfeeding ( EBF ) until 6 mo or to receive high- quality , hygienic solid foods ( SF ) in addition to breast milk between 4 and 6 mo .  Maternal weight loss between 4 and 6 mo was significantly greater in the exclusive breastfeeding group ( EBF ) group than in the group(s ) given solid foods ( SF ) in study 1 ( -0.7 + /- 1.5 versus -0.1 + /- 1.7 kg , P < 0.05 ) but not in study 2 . The estimated average additional nutritional burden of continuing to exclusively breastfeed until 6 mo was small , representing only 0.1 - 6.0 % of the recommended dietary allowance for energy , vitamin A , calcium and iron . Women in the EBF group were more likely to be amenorrheic at 6 mo than women in the SF group , which conserves nutrients such as iron . In both studies , few women ( 10 - 11 % ) were thin ( body mass index < 19 kg/m(2 ) ) , so the additional weight loss in the EBF group in study 1 was unlikely to have been detrimental . Infants in the EBF group crawled sooner ( both studies ) and were more likely to be walking by 12 mo ( study 1 ) than infants in the SF group . Taken together with our previous findings , these results indicate that the advantages of exclusive breastfeeding during this interval appear to outweigh any potential disadvantages in this setting Objectives . In Switzerl and , the Baby-Friendly Hospital Initiative ( BFHI ) proposed by the United Nations Children 's Fund ( UNICEF ) was introduced in 1993 to promote breastfeeding nationwide . This study reports results of a national study of the prevalence and duration of breastfeeding in 2003 throughout Switzerl and and analyzes the influence of compliance with UNICEF guidelines of the hospital where delivery took place on breastfeeding duration . Methods . Between April and September 2003 , a r and om sample of mothers who had given birth in the past 9 months in Switzerl and received a question naire on breastfeeding and complementary feeding . Seventy-four percent of the contacted mothers ( n = 3032 ) participated ; they completed a 24-hour dietary recall question naire and reported the age at first introduction of various foods and drinks . After excluding question naires with missing information relevant for the analyses , we analyzed data for 2861 infants 0 to 11 months of age , born in 145 different health facilities . Because it was known whether each child was born in a design ated baby-friendly hospital ( 45 hospitals ) or in a health facility in the process of being evaluated for BFHI inclusion ( 31 facilities ) , we were able to assess a possible influence of the BFHI on breastfeeding success . For this purpose , we merged individual data with hospital data on compliance with the UNICEF guidelines , from a data source collected on an annual basis for quality monitoring of design ated baby-friendly hospitals and health facilities in the evaluation process . Information on actual compliance with the guidelines allowed us to investigate the relationship between breastfeeding outcomes and compliance with UNICEF guidelines . We were also able to compare the breastfeeding results with those for non – baby-friendly health facilities . The comparison was based on median duration s of exclusive , full , and any breastfeeding calculated for each group . To allow for other known influencing factors , we calculated adjusted hazard ratios by using Cox regression ; we also conducted logistic regression analyses with the 24-hour dietary recall data , to calculate adjusted odds ratios for validation of results from the retrospectively collected data . Results . In 2003 , the median duration of any breastfeeding was 31 weeks at the national level , compared with 22 weeks in 1994 , and the median duration of full breastfeeding was 17 weeks , compared with 15 weeks in 1994 . The proportion of exclusively breastfed infants 0 to 5 months of age was 42 % for infants born in baby-friendly hospitals , compared with 34 % for infants born elsewhere . Breastfeeding duration for infants born in baby-friendly hospitals , compared with infants born in other hospitals , was longer if the hospital showed good compliance with the UNICEF guidelines ( 35 weeks vs 29 weeks for any breastfeeding , 20 weeks vs 17 weeks for full breastfeeding , and 12 weeks vs 6 weeks for exclusive breastfeeding ) . To control for differences in the study population between the different types of health facilities , hazard and odds ratios were calculated as described above , taking into account socioeconomic and medical factors . Although the analysis of the retrospective data showed clearly that the duration of exclusive and full breastfeeding was significantly longer if delivery occurred in a baby-friendly hospital with high compliance with the UNICEF guidelines , whereas this effect was less prominent in other baby-friendly health facilities , this difference was less obvious in the 24-hour recall data . Only for the duration of any breastfeeding could a positive effect be seen if delivery occurred in a baby-friendly hospital with high compliance with the UNICEF guidelines . Known factors involved in the evaluation of baby-friendly hospitals showed the expected influence , on the individual level , on duration of exclusive , full , and any breastfeeding . If a child had been exclusively breastfed in the hospital , the median duration of exclusive , full , and any breastfeeding was considerably longer than the mean for the entire population or for those who had received water-based liquids or supplements in the hospital . A positive effect on breastfeeding duration could be shown for full rooming in , first suckling within 1 hour , breastfeeding on dem and , and also the much-debated practice of pacifier use . After controlling for medical problems before , during , and after delivery , type of delivery , well-being of the mother , maternal smoking , maternal BMI , nationality , education , work , and income , all of the factors were still significantly associated with the duration of full , exclusive , or any breastfeeding . Conclusions . Our results support the hypothesis that the general increase in breastfeeding in Switzerl and since 1994 can be interpreted in part as a consequence of an increasing number of baby-friendly health facilities , whose clients breastfeed longer . Nevertheless , several alternative explanations for the longer breastfeeding duration for deliveries that occurred in baby-friendly hospitals can be discussed . In Switzerl and , baby-friendly hospitals actively use their certification by UNICEF as a promotional asset . It is thus possible that differences in breastfeeding duration are attributable to the fact that mothers who intend to breastfeed longer would choose to give birth in a baby-friendly hospital and these mothers would be more willing to comply with the recommendations of the UNICEF guidelines . Even if this were the case , however , this selection bias would not explain the differences in breastfeeding duration between design ated baby-friendly health facilities with higher compliance with the UNICEF guidelines and those with lower compliance . Especially this last point strongly supports a beneficial effect of the BFHI , because mothers do not know how well hospitals comply with the UNICEF program . The fact that breastfeeding rates have generally improved even in non – baby-friendly health facilities may be indirectly influenced by the BFHI ; its publicity and training programs for health professionals have raised public awareness of the benefits of breastfeeding , and the number of professional lactation counselors has increased continuously . Breastfeeding prevalence and duration in Switzerl and have improved in the past 10 years . Children born in a baby-friendly health facility are more likely to be breastfed for a longer time , particularly if the hospital shows high compliance with UNICEF guidelines . Therefore , the BFHI should be continued but should be extended to include monitoring for compliance , to promote the full effect of the BFHI Aim : To assess breastfeeding practice s using the World Health Organization/United Nations Children 's Fund ( WHO/UNICEF ) Ten Steps to Successful Breastfeeding for Baby‐Friendly Hospitals in unselected non‐UNICEF certified German hospitals and to examine the influences of breastfeeding promotion on long‐term breastfeeding success as assessed by WHO criteria . Methods : Information on the fulfilment of the Ten Steps was collected in 177 r and omly chosen maternity hospitals by a postal question naire .  Breastfeeding duration  was assessed in 1487 mothers delivering in these hospitals .  Multiple logistic regression was used to estimate the association between a low breastfeeding promotion index , defined as fulfilment of fewer than five steps , and the risk of short‐term breastfeeding , less than 4 mo . Results : A higher breastfeeding promotion index was not associated with early breastfeeding but was significantly associated with full breastfeeding at 4 and 6 mo . After adjusting for confounding factors , delivering in a hospital with a low breastfeeding promotion index was associated with an increased risk of short‐term breastfeeding [ odds ratio ( OR ) 1.24 ] , although associations with maternal demographic variables ( young age : OR 3.34 ) , low educational level ( OR 2.81 ) and upbringing in East Germany ( OR 2.27 ) were stronger In a prospect i ve multicentre study on 926 preterm infants formally assigned to their early diet , necrotising enterocolitis developed in 51 ( 5.5 % ) .  Mortality was 26 % in stringently confirmed cases . In exclusively  formula-fed  babies confirmed disease was 6 - 10 times more common than in those fed breast milk alone and 3 times more common than in those who received formula plus breast milk . Pasteurised donor milk seemed to be as protective as raw maternal milk . Among babies born at more than 30 weeks ' gestation confirmed necrotising enterocolitis was rare in those whose diet included breast milk ; it was 20 times more common in those fed formula only . Other risk factors included very low  gestational age , respiratory disease , umbilical artery catheterisation , and polycythaemia . In formula-fed but not breast-milk-fed infants , delayed enteral feeding was associated with a lower frequency of necrotising enterocolitis . With the fall in the use of breast milk in British neonatal units , exclusive formula feeding could account for an estimated 500 extra cases of necrotising enterocolitis each year . About 100 of these infants would die Abstract Problem : Breastfeeding rates and related hospital practice s need improvement in Italy and elsewhere . Training of staff is necessary , but its effectiveness needs assessment . Context : Eight hospitals in different regions of Italy . Design : Controlled , non-r and omised study . Data collected in three phases . Training after the first phase in group 1 hospitals and after the second phase in group 2 . Strategies for change : Training of trainers and subsequent training of health workers with a slightly adapted version of the 18 hour Unicef course on breastfeeding management and promotion . Key measures for improvement : Hospital practice s , knowledge of 571 health workers  , and  breastfeeding rates at discharge , three , and six months in 2669 mother and baby pairs . Effects of change : After training hospitals improved their compliance with the “ ten steps to successful breast feeding , ” from an average of 2.4 steps at phase one to 7.7 at phase three . Knowledge scores of health professionals increased from 0.41 to 0.72 in group 1 ( training after phase one ) and from 0.53 to 0.75 in group 2 ( after phase two ) . The rate of exclusive breast feeding at discharge increased significantly after training : 41 % to 77 % in group 1 and 23 % to 73 % in group 2 , as did the rates of full ( exclusive plus predominant ) breast feeding at three months ( 37 % to 50 % in group 1 v 40 % to 59 % in group 2 ) and any breast feeding at six months ( 43 % to 62 % in group 1 v 41 % to 64 % in group 2 ) . Lessons learnt : Training for at least three days with a course including practical sessions and counselling skills is effective in changing hospital practice s , knowledge of health workers , and breastfeeding rates CONTEXT Current evidence that breastfeeding is beneficial for infant and child health is based exclusively on observational studies . Potential sources of bias in such studies have led to doubts about the magnitude of these health benefits in industrialized countries . OBJECTIVE To assess the effects of breastfeeding promotion on breastfeeding duration and exclusivity and gastrointestinal and respiratory infection and atopic eczema among infants . DESIGN The Promotion of Breastfeeding Intervention Trial ( PROBIT ) , a cluster-r and omized trial conducted June 1996-December 1997 with a 1-year follow-up . SETTING Thirty-one maternity hospitals and polyclinics in the Republic of Belarus . PARTICIPANTS A total of 17 046 mother-infant pairs consisting of full-term singleton infants weighing at least 2500 g and their healthy mothers who intended to breastfeed , 16491 ( 96.7 % ) of which completed the entire 12 months of follow-up . INTERVENTIONS Sites were r and omly assigned to receive an experimental intervention ( n = 16 ) modeled on the Baby-Friendly Hospital Initiative of the World Health Organization and United Nations Children 's Fund , which emphasizes health care worker assistance with initiating and maintaining breastfeeding and lactation and postnatal breastfeeding support , or a control intervention ( n = 15 ) of continuing usual infant feeding practice s and policies . MAIN OUTCOME MEASURES Duration of any breastfeeding , prevalence of predominant and exclusive breastfeeding at 3 and 6 months of life and occurrence of 1 or more episodes of gastrointestinal tract infection , 2 or more episodes of respiratory tract infection , and atopic eczema during the first 12 months of life , compared between the intervention and control groups . RESULTS Infants from the intervention sites were significantly more likely than control infants to be breastfed to any degree at 12 months ( 19.7 % vs 11.4 % ; adjusted odds ratio [ OR ] , 0.47 ; 95 % confidence interval [ CI ] , 0.32 - 0.69 ) , were more likely to be exclusively breastfed at 3 months ( 43.3 % vs 6.4 % ; P<.001 ) and at 6 months ( 7.9 % vs 0.6 % ; P = .01 ) , and had a significant reduction in the risk of 1 or more gastrointestinal tract infections ( 9.1 % vs 13.2 % ; adjusted OR , 0.60 ; 95 % CI , 0.40 - 0.91 ) and of atopic eczema ( 3.3 % vs 6.3 % ; adjusted OR , 0.54 ; 95 % CI , 0.31 - 0.95 ) , but no significant reduction in respiratory tract infection ( intervention group , 39.2 % ; control group , 39.4 % ; adjusted OR , 0.87 ; 95 % CI , 0.59 - 1.28 ) . CONCLUSIONS Our experimental intervention increased the duration and degree ( exclusivity ) of breastfeeding and decreased the risk of gastrointestinal tract infection and atopic eczema in the first year of life . These results provide a solid scientific underpinning for future interventions to promote breastfeeding The purpose of this study was to evaluate the implementation of a change to the breastfeeding policy in seven hospitals in accordance with the ' Ten Steps to Successful Breastfeeding ' issued by the World Health Organization and the United Nations Children 's Fund and to assess the impact of hospital practice s on breastfeeding . A 3-year quasi-experimental pre-post test design was conducted in 12 hospitals . The subjects were composed of 4614 lactating women in both experimental and control groups . The research instruments included the Baby-Friendly hospital Initiative training programs and question naires on breastfeeding duration , knowledge , attitude , and demographic data . Breastfeeding rates ( including exclusive breastfeeding , mixed breastfeeding , and overall breastfeeding rates ) of the experimental and control groups were measured and compared at four different times , during the hospital stay and at 2 weeks , 1 and 2 months postpartum . The results indicated that the exclusive and overall breastfeeding rates of the experimental group were higher than those of the control group ( p < 0.001 ) ; moreover , the breastfeeding rates generally exhibited an increasing trend year by year ( ( p < 0.001 ) . The results also showed that the experimental group scored higher in breastfeeding knowledge than the control group as did positive attitudes toward breastfeeding ( t > 1.96 , p < 0.05 ) with scores increasing year by year . The results also showed that higher scores reflected better knowledge in breastfeeding , and , in turn , a longer duration of breastfeeding OBJECTIVE Breastfeeding initiation rates were compared at Boston Medical Center before ( 1995 ) , during ( 1998 ) , and after ( 1999 ) Baby-Friendly policies were in place . Boston Medical Center , an inner-city teaching hospital that provides care primarily to poor , minority , and immigrant families , achieved Baby-Friendly status in 1999 . METHODS Two hundred complete medical records , r and omly selected by a computer , were review ed from each of 3 years : 1995 , 1998 , and 1999 . Infants were excluded for medical records missing feeding data , human immunodeficiency virus-positive parent , neonatal intensive care unit admission , maternal substance abuse , adoption , incarceration , or hepatitis C-positive mother . All infant feedings during the hospital postpartum stay were tallied , and each infant was categorized into 1 of 4 groups : exclusive breast milk , mostly breast milk , mostly formula , and exclusive formula . RESULTS Maternal and infant demographics for all 3 years were comparable . The breastfeeding initiation rate increased from 58 % ( 1995 ) to 77.5 % ( 1998 ) to 86.5 % ( 1999 ) . Infants exclusively breastfed increased from 5.5 % ( 1995 ) to 28.5 % ( 1998 ) to 33.5 % ( 1999 ) . Initiation rates increased among US-born black mothers in this population from 34 % ( 1995 ) to 64 % ( 1998 ) to 74 % ( 1999 ) . CONCLUSIONS Full implementation of the Ten Steps to Successful Breastfeeding leading to Baby-Friendly design ation is an effective strategy to increase breastfeeding initiation rates in the US hospital setting AIM To assess the possible protective effect of exclusive breastfeeding against  first-time febrile urinary tract infection ( UTI ) in children . METHODS Two children 's hospitals and local child health centres in the Göteborg area , Sweden , participated in a prospect i ve case-control study . In total , 200 consecutive cases ( 89 M , 111F ) , aged 0 - 6y , presenting with first-time febrile UTI were enrolled . The mean + /- SD age was 0.98 + /- 1.15 y. As control subjects , 336 children ( 147 M , 189F ) were recruited from the child health centre of the case , matched for age and gender and included consecutively for each case during the first days after diagnosis . The duration of exclusive breastfeeding was obtained from the case and controls by a st and ardized procedure . RESULTS Ongoing exclusive breastfeeding gave a significantly lower risk of infection . A longer duration of breastfeeding gave a lower risk of infection after weaning , indicating a long-term mechanism . The protective role of breastfeeding was strongest directly after birth , then decreased until 7 mo of age , after which age no effect was demonstrated . CONCLUSION A protective role of breastfeeding against UTI was demonstrated . The study provides statistical support to the view that breast milk is a part of the natural defence against UTI BACKGROUND Promotion of breastfeeding is an important child-survival intervention , yet little is known about which promotional strategies are the most effective . We aim ed to compare the effects on rates of breastfeeding of two systems for promotion of breastfeeding in Brazil -- a hospital-based system and the same system combined with a programme of home visits . METHODS In February , 2001 , maternity staff from two hospitals in Pernambuco , Brazil , were trained according to the Baby-Friendly Hospital Initiative ( BFHI ) . In a r and omised trial between March and August , 2001 , 350 mothers giving birth at these hospitals were assigned ten postnatal home visits to promote and support breastfeeding ( n=175 ) or no home visits ( n=175 ) . Breastfeeding practice s were studied on days 1 , 10 , 30 , 60 , 90 , 120 , 150 , and 180 by research ers unaware of group allocation . The primary outcome measure was the rate of exclusive breastfeeding from birth to 6 months . Analyses were by intention to treat . FINDINGS The hospital-training intervention achieved a high rate ( 70 % ) of exclusive breastfeeding in the hospitals , but this rate was not sustained at home and at 10 days of age only 30 % of infants were exclusively breastfed The patterns of exclusive breastfeeding in the two trial groups for days 10 - 180 differed significantly ( p<0.0001 ) , with a mean aggregated prevalence of 45 % among the group assigned home visits compared with 13 % for the group assigned none . INTERPRETATION The BFHI achieves high rates of exclusive breastfeeding in hospital ; however , in Brazil at least , the rates fall rapidly thereafter . Reliance on the BFHI as a strategy for breastfeeding promotion should be reassessed . A combination of promotional systems ( hospital-based and in the community ) is needed The Baby-Friendly Hospital Initiative ( BFHI ) is based on the Ten Steps to Successful Breast-Feeding , a program which summarize the practice s that maternity wards need to adopt to support breastfeeding.1 There are more than 16 000 Baby-Friendly Hospitals throughout the world , and of these , more than 200 are located in Brazil . Despite the abundance of studies evaluating each of the 10 steps or a combination of them , information on the impact of BFHI on the duration of breastfeeding is limited . Recently , a large r and omized controlled trial including 31 hospitals in Belarus showed that an intervention based on BFHI principles increased breastfeeding rates , especially exclusive breastfeeding.2 The present study reproduced these results using a less complex study design OBJECTIVES This study examined the effectiveness of a hospital program to promote exclusive breast-feeding in Santos , Brazil . METHODS In a prospect i ve design , women who delivered at a hospital with an active breast-feeding promotion program ( n = 236 ) were compared with women who delivered at a nearby control hospital ( n = 206 ) . RESULTS The two groups had similar demographic characteristics and previous breast-feeding histories .  Exposure to breast-feeding activities , assessed by maternal recall prior to discharge , was universally high at the program hospital and universally low at the control hospital . Multivariate survival analysis showed that exclusive breast-feeding lasted 53 days longer among women who delivered at the program hospital . CONCLUSIONS Hospital-based breast-feeding promotion programs may be effective in extending the duration of exclusive breast-feeding
EXECUTIVE SUMMARY Background : Breastfeeding has many important health benefits for the woman and her baby .
Despite evidence of benefit from a large number of well conducted studies , breastfeeding uptake and the duration of exclusive breastfeeding remain low in many countries .
In order to improve breastfeeding rates , policy and guidelines at global , individual country level and in local healthcare setting s have recommended that structured programmes to support breastfeeding should be introduced .
The objective of this review was to consider the evidence of outcomes of structured compared with non-structured breastfeeding programmes in acute maternity care setting s to support initiation and duration of exclusive breastfeeding .