The Baby Friendly Hospital Initiative and Breastfeeding Duration : Relating the Evidence to the Australian Context

Objective: The Baby Friendly Hospital Initiative (BFHI) is an effort by UNICEF and WHO to improve society’s health through promoting, protecting and supporting breastfeeding. The key strategy in this initiative is in transforming care of newborn infants in maternity hospitals. The recently published Australian Breastfeeding Leadership Plan (ABLP) strongly advocates, as part of its overall plan to increase breastfeeding rates in Australia, the use of public funding and support to implement the BFHI in Australian hospitals. The purpose of this review is to present evidence related to the BFHI’s impact upon breastfeeding duration, comment upon the relevance of this evidence to the Australian context, with a view to engendering discussion about the value of the BFHI in an environment where enhancement of breastfeeding duration appears to be the primary goal. Findings: Australia finds itself in the unique situation of being a high-income country with comparatively high initiation of exclusive breastfeeding and rapid deterioration in exclusive breastfeeding rates to six months, in part because solid foods are introduced early. While the BFHI itself has been shown to increase the duration of exclusive breastfeeding, much of the evidence is derived from studies where exclusive breastfeeding initiation is low prior to implementation or there are major socioeconomic or cultural differences between study contexts and the context observed in Australia. Principal Conclusions: There is little evidence to suggest that BFHI implementation has a positive impact upon breastfeeding duration in the Australian context. There is an urgent need for research in this area to inform stakeholders in breastfeeding. While implementation of BFHI principles might protect against the deterioration of breastfeeding initiation, limited resources might be better utilised by directing them toward initiatives outlined in the ABLP that are known to increase breastfeeding duration in the Australian context, like improving workplace conditions for breastfeeding and enhancing the knowledge of health professionals in the community, such as general practitioners, who are likely to provide breastfeeding support to these mothers once they leave hospital. The Baby Friendly Hospital Initiative and Breastfeeding Duration: Relating the Evidence to the Australian Context There is well-documented and steadily accumulating evidence that exclusive breastfeeding for periods of six months is important in preventing health problems in both the infant and the mother. There is also ample evidence that a number of factors have association with the length of time for which a woman exclusively breastfeeds her child. Socio-demographic factors such as age and return to paid work, social factors such as the father’s infant feeding preference and level of support for breastfeeding from family and friends, and mothering practices such as the timing of the introduction of solids, and use of a pacifier, and psychological factors such as the timing of the feeding decision 8 and mothers’ confidence in their ability to breastfeed 9 have all been shown to influence exclusive breastfeeding duration. There is some evidence that certain hospital practices, such as early skin-to-skin contact after birth, having the mother and infant together during their hospital stay, and early discharge from hospital, have an influence on whether a mother initiates and maintains exclusive breastfeeding. 10 The Baby Friendly Hospital Initiative (BFHI) was launched in 1991, and represented an intensive effort on behalf of the World Health Organisation (WHO) and the United Nations Children’s Fund (UNICEF) to transform practice in maternity hospitals. The aim of the BFHI was to protect, promote and support breastfeeding globally. The BFHI was given in-principle support by the Australian government in 1993. Since 1995, the Australian College of Midwives has been in charge of facilitating this initiative. The Australian Breastfeeding Leadership Plan (ABLP) was prepared by the Australian Breastfeeding Association (ABA) to encourage debate and action. In this plan, the BFHI is advocated as part of a multi-pronged attack designed to increase breastfeeding rates in Australia. The plan includes other initiatives such as encouraging breastfeeding-friendly workplaces and removing financial disincentives to breastfeeding. The 10 steps to successful breastfeeding advocated in the BFHI are: (1) having a written breastfeeding policy that is routinely communicated to all staff; (2) providing training in implementation skills to all health staff; (3) informing all pregnant women about the benefits and management of breastfeeding; (4) promoting initiation of breastfeeding within half an hour of birth; (5) showing mothers how to breastfeed and maintain lactation, even if they are separated from their infants; (6) providing breast milk only, unless medically indicated; (7) allowing mothers and their infants to remain together 24 hours a day (rooming-in); (8) encouraging breastfeeding on demand; (9) providing no artificial teats or dummies; and (10) fostering establishment of and referral to breastfeeding support groups. Currently, there are 51 BFHI-accredited maternity hospitals in Australia , and active promotion of the BFHI figures prominently in the strategies outlined in the ABLP. Additionally, the ABLP advocates provision of funding and support for BFHI implementation in Australia, BFHI-accreditation of 50% of maternity hospitals in Australia by 2008, and linking of public funding of maternity hospitals to BFHI accreditation by 2014. There is ample evidence from both developed 14 and developing countries , as defined according to the United Nations, to suggest that implementation of the BFHI produces significant and marked increases in initiation of exclusive breastfeeding, particularly where these rates are low prior to implementation. Initiation of exclusive breastfeeding, however, does not appear to be the major issue of concern in Australia. Australia, in fact, finds itself in a relatively unique context in relation to breastfeeding. It is a high-income country where initiation of breastfeeding is comparatively high, with recent estimates of initiation of any breastfeeding at between 83% and 93% and estimates of exclusive initiation of breastfeeding at over 80%. This differs from other high-income countries such as the USA, where initiation of exclusive breastfeeding is historically low. Duration of breastfeeding in Australia, however, is poor, with only 27% of mothers exclusively breastfeeding their child to 4 months and 5% exclusively breastfeeding to six months postpartum. 21 Studies examining the effects of BFHI interventions on breastfeeding duration are reasonably common in the literature, and evidence from this literature base is commonly used to make the argument for the implementation of the BFHI in Australian maternity hospitals. It is not known how much of this research is conducted in situations that even roughly match those present in Australia. The authors thought it timely to examine the empirical basis upon which these assertions are made to discover whether the widespread implementation of the BFHI is a useful and worthwhile strategy for increasing exclusive breastfeeding duration in the Australian context. The literature regarding the impact of BFHI implementation on duration of breastfeeding was examined. A broad review of the research, including a systematic review in 2000, related to the impact of BFHI implementation on breastfeeding duration, is presented. Research is presented first from contexts in which breastfeeding initiation rates are low in comparison to those observed in Australia. Research from contexts closer to those observed in Australia is then presented. Finally, the relevant literature from research conducted within Australia is explored. Systematic Review of Effectiveness of the BFHI 24 In 2000, Fairbank et al. 24 conducted a systematic review of studies designed to promote the initiation of breastfeeding. As part of this review, they examined randomised controlled trials of BFHI implementation to determine the impact of the BFHI upon both the initiation and duration of exclusive breastfeeding. They concluded from the evidence collected that exclusive breastfeeding duration is improved by introduction of BFHI principles. This conclusion, however, is based upon a single study conducted in Thailand. The results of this study will be examined later, though one would caution against concluding that a particular intervention is effective on the basis of results from a single study. Additionally, considerable research into the impact of the BFHI on breastfeeding duration has been conducted since that time. A broader review of research conducted on this topic was therefore warranted. The Effect of the BFHI in Countries with Low Breastfeeding Initiation Rates Examination of the literature of the BFHI’s effect on breastfeeding duration reveals that most of the available evidence has been collected from contexts in which initiation of exclusive breastfeeding is low (i.e., below 50%). Bellamy 15 summarised the impact of a number of BFHI implementations on breastfeeding duration, with generally very positive results. In Iran, for example, rates of exclusive breastfeeding at four months postpartum were 10% pre-BFHI and increased to 53% post-BFHI. In China, BFHI implementation increased exclusive breastfeeding rates at 4 months postpartum from 10% to 48% in urban areas and from 29% to 68% in rural areas. In Chile, exclusive breastfeeding rates at 6 months increased from 4% pre-BFHI to 40% post-BFHI. Many of these studies, however, are not specific about whether the statistics presented for exclusive breastfeeding duration relate to all mothers giving birth, including mothers who did not initiate breastfeeding, or just to mothers who initiated breastfeeding. It could be argued that the in