Breastfeeding Initiation and Birth Setting Practices: A Review of the Literature

Della A. Forster, RN, RM, PhD; Helen L. McLachlan, RN, RM, PhD


J Midwifery Womens Health. 2007;52(3):273-280. 

In This Article

Birth Setting and the Impact of BFHI

The setting in which a woman gives birth may have an impact on her breastfeeding outcomes. A large retrospective cohort study in the United States explored the impact of variations in practice at different hospitals as a component of breastfeeding outcomes, compared with expectations based on maternal and newborn demographic characteristics.[12] The authors found that while approximately 60% of the variation in breastfeeding was predicted by sociodemographic factors, other contributing factors, such as hospital practices, significantly contributed to breastfeeding outcomes.[12] Another study found that even among more motivated women, the quality of breastfeeding support in hospital made a difference to breastfeeding success, with only 22% of mothers reporting breastfeeding support as "very good."[13]

A number of studies have reported positive breastfeeding outcomes for women who give birth in BFHI-accredited hospitals, or where a number of the Ten Steps are in place. The first three of the Ten Steps ( Table 1 ) relate to hospital policies and practices. A Scottish study found that babies born in BFHI-accredited hospitals were 28% more likely to be exclusively breastfed at 7 days postpartum.[14] In Italy, a controlled, nonrandomized study demonstrated a significant increase in breastfeeding at 6 months postpartum where women attended hospitals in which health workers had undergone the UNICEF 18-hour course[15] in breastfeeding[16] compared with the time before the education. A cluster randomised trial in Belarus where maternity hospitals were randomized to receive an intervention modeled on BFHI or to continue with usual infant feeding practices and policies found an increase in the duration and exclusivity of breastfeeding as well as a decreased incidence of gastrointestinal disease and atopic eczema during the first year of life.[17] In an inner city teaching hospital in Boston serving mainly poor, minority, and immigrant families, full and continued application of the Ten Steps had an extended positive impact on breastfeeding rates.[18] Finally, a large cross-sectional Swiss study found that children born in a Baby-Friendly hospital were more likely to be breastfed for longer, particularly in settings where BFHI compliance is high.[19]

DiGirolamo et al.[20] assessed indicators of five of the ten BFHI practices in a longitudinal study on infant feeding practices, which included women who initiated breastfeeding and who had expressed a prenatal intention to breastfeed. The authors found a positive relationship between the number of these steps in place and breastfeeding outcomes; women experiencing fewer BFHI practices were more likely to cease breastfeeding by 6 weeks, with a dose-related response relationship, which suggests that the cumulative effect of the practices, as opposed to each individual practice, is important. They also found some factors significantly associated with early cessation of breastfeeding: late initiation of breastfeeding (adjusted OR, 1.6; 95% CI, 1.1-2.3); the baby receiving infant formula supplementation (adjusted OR, 2.3; 95% CI, 1.5-3.3); and not breastfeeding on demand (adjusted OR, 1.2; 95% CI, 0.8-1.7).

A study in Brazil[21] assessed the effect of educating maternity staff via the 18-hour UNICEF/WHO course on breastfeeding[15] and found a significant increase in the rate of exclusive breastfeeding in hospital (70%), although this was not sustained (30% by postpartum day 10), possibly because of the very short length of postnatal stay (24-36 hours for women who had normal births and 48 hours for women who gave birth by caesarean section). Although adopting BFHI strategies increased rates of exclusive breastfeeding in hospital, relying on these strategies alone is unlikely to be effective in increasing breastfeeding duration.[21]

A systematic review that evaluated the effectiveness of interventions used to promote the initiation of breastfeeding found that breastfeeding initiation is increased in hospitals that have a written policy.[22] The Academy of Breastfeeding Medicine has a "model" written policy for hospitals wanting to create or update their breastfeeding policies.[23] The model is freely accessible online.

Staff attitudes to infant feeding may influence women. One study reported that if hospital staff expressed no preference for type of infant feeding or if they favoured formula, women were less likely to be breastfeeding at 6 weeks.[24] This was particularly so for those women who intended to breastfeed for 2 months or less. In this study, women perceived that only 42% of hospital staff expressed a preference for type of infant feeding.

Given the increasing evidence of the positive breastfeeding outcomes associated with women receiving care in BFHI-accredited hospitals, all centres that provide maternity care should be working towards the BFHI strategies and implementation of the Ten Steps.


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