Successful Application of the Baby-Friendly Hospital Initiative Contains Lessons That Must Be Applied to the Control of Formula Feeding in Hospitals in Industrialized Countries

The health risks of artificial feeding of infants in the industrialized world are now well-established—breastfed infants receive protection against illnesses including gastroenteritis, respiratory infections, and otitis media, and have a lower risk of atopic disease and insulin-dependent diabetes in childhood, while women who breastfeed may have less risk of some cancers and hip fractures in later life.1,2 In addition to the health benefits, there are also significant cost implications—the US Department of Agriculture has estimated that a minimum of $3.6 billion per year would be saved if breastfeeding rates were increased from current levels to those recommended by the US Surgeon General.3 What is less clear is how society as a whole and the health services in particular should go about reversing the decline in breastfeeding. The evaluation by Philipp and colleagues in this issue ofPediatrics,4 which found that breastfeeding rates at the Boston Medical Center (BMC) rose by 28.5% over 4 years, during which the maternity unit achieved accreditation by the Baby-Friendly Hospital Initiative (BFHI) is therefore interesting for a number of reasons.Although breastfeeding can also be promoted by improving facilities in the public environment, addressing workplace issues, and providing education in schools—and indeed efforts have been made in this direction5,6—it is in maternity hospitals and subsequently in the community health services where both the biggest obstacles and the greatest opportunities are presented. In recognition of the importance of the maternity services, the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) have developed the 10 steps to successful breastfeeding.7The BFHI supports and encourages hospitals to adopt the 10 steps as policy and practice in the maternity unit. The standards provide a basis for good practice by requiring a written policy, a staff education program, and full information for all women booked to deliver at the hospital. Changes to hospital routines ensure that practices such as unnecessary separation of mother and infant or inappropriate supplementation with formula or water are ended, and continuity is provided by giving mothers information about how to get additional breastfeeding support after they return home.8As all staff need to be trained and strategies adopted to ensure practice is changed, adopting the Baby-Friendly standards clearly takes time. The dose-response effect observed in the BMC study, with breastfeeding initiation rising from 55% before the initiative was begun, to 77.5% part-way through and to 86.5% at the time of accreditation suggests that the implementing the standards is at least as important as the final award. This implies that a point is reached during the adoption of the 10 steps when the process is sufficiently underway for benefits to be observed, while the maximum benefit is achieved once all steps are fully in place. This observation is supported by the experience of Scottish Hospitals—Baby-Friendly hospitals increased their breastfeeding rate at 7 days by 8.1% over an 8-year period, compared with a rise of just 2.2% among hospitals without a Baby-Friendly award. Units, which had been recognized for adopting at least 3 steps, had added 6.1% over the same period.9 Those maternity hospitals, which perceive Baby-Friendly designation as a distant goal, should take heart.The American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months after birth10 and the BMC has had some success in increasing the proportion of infants exclusively breastfed from 5.5% in 1995% to 33.5% in 1999. Nevertheless, the criteria for accreditation as a Baby-Friendly Hospital state that no breastfed infant should receive a supplementary feed unless it is medically indicated, the result of informed maternal choice, or other reason beyond the control of the facility.8 It appears that by the time of the assessment for Baby-Friendly accreditation, practices at the BMC were in line with these criteria and that poorer, yet improving data from earlier in the year have resulted in a seemingly high level of supplementation of breastfed infants over the full 12 months (C. Turner-Maffei, Baby-Friendly USA, 8 Jan Sebastian Way #13, Sandwich MA, 02563, personal communication, May 30, 2001). To have turned around this problem, virtually eliminating unnecessary additional formula feeds, while simultaneously ending a relationship with an infant formula manufacturer which was supplying the unit free of charge with more than 3 times the amount of formula than it actually needed, is worthy of additional commendation. The free supply of infant formula is widespread in the United States11 yet is not compatible with Baby-Friendly accreditation. If more units are to be enabled to end their reliance on the formula industry, national legislation to prohibit such donations is required. This would be in line with the WHO/UNICEFInternational Code of Marketing of Breastmilk Substitutes.12As the study's authors point out, the differing prevalence of breastfeeding between different populations exposes a range of inequalities. This reflects the situation in other industrialized countries—in the United Kingdom, for example, women are significantly more likely to breastfeed if they belong to a higher socioeconomic group, remain in full-time education longer, and delay their first pregnancy beyond age 30.13 There is a depressing irony in a situation in which infants who are born into disadvantaged communities and who should therefore gain the greatest benefit from the advantages of breastfeeding are the least likely to receive them. Nevertheless, the experience at the BMC, where breastfeeding rates increased among US-born black mothers (traditionally having a low rate of breastfeeding in the United States) and women with Medicaid or no health insurance, suggests that the BFHI is an effective tool for addressing such inequalities.The staff of the BMC therefore deserves our congratulations for their determination to improve care provided for breastfeeding mothers and infants. In doing so, the hospital has reduced inequalities in health, broken free of its dependency on the infant formula industry, and shown that Baby-Friendly accreditation is achievable in an inner-city hospital serving an urban, deprived population. Readers whose hospitals are not yet so accredited could use the current study to advocate for an action plan to follow suit. The challenge now is to maintain these breastfeeding increases beyond the sphere of influence of the maternity services so that more infants are breastfed for 6 months and beyond. This may be assisted by extending the BFHI to community health centers as has been developed in the United Kingdom and Canada (M. Sanders, Breastfeeding Committee for Canada, personal communication, May 28, 2001)14 and adopting the standards of the BFHI as part of a broader program (the Child Friendly Healthcare Initiative) currently being piloted in 5 countries.15

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