DOI: 10.25442/hku.16557999.v1
title: The effect of Baby-Friendly Hospital Initiative implementation, accreditation and certification on breastfeeding outcomes of pregnant women in Hong Kong

description: Breast milk is the best source of nutrition for infants. However, numerous barriers prevent women from breastfeeding for the optimal duration recommended by the World Health Organization and the United Nations Children’s Fund. Overwhelming evidence in the literature shows a number of benefits of breastfeeding for women and children. Many interventions and policies have been implemented to improve breastfeeding rates. One of these is the Baby-Friendly Hospital Initiative (BFHI) launched in 1991 to promote breastfeeding through hospital policy. The BFHI is a group of ten steps applied at a maternal health centre that affects hospital practices. Many studies have reported that BFHI results in the improvement in breastfeeding. However, there have been inconsistent results and pre-post studies on the BFHI are limited. No study has compared the effects of the different stages of the BFHI designation process on breastfeeding. Therefore, the objective of this study is to examine the effects of BFHI implementation, certification, and accreditation on breastfeeding duration and exclusivity at four geographically-distributed public postnatal wards in Hong Kong. This was a multicentre repeated prospective cohort that took place in Hong Kong. A total of 2369 mother-infant dyads were recruited in this study. The two cohorts in this study were investigated at two different times: before (pre-BFHI) and after implementation of the BFHI (post-BFHI). Recruitment for pre-BFHI took place from 2011-2012 (n=1240) and post-BFHI took place from 2017-2018 (n=1129). Participants were followed up through telephone interviews at 1, 3, and 6 months after birth or until breastfeeding had stopped. Several statistical methods such as the chi-square test, Cox proportional hazards regression and propensity score weighting were used throughout the thesis. Improvements in the duration and exclusivity of breastfeeding were observed with BFHI implementation. After adjusting for confounders, participants in the post-BFHI cohort had 56% (aHR= 0.44; 95% CI: 0.38-0.49) and 56% (aHR= 0.44; 95% CI: 0.40-0.49) lower risks of discontinuing any and exclusive breastfeeding, respectively. Becoming a Baby-Friendly Hospital (accreditation) was associated with a 58% (aHR= 0.42; 95% CI: 0.34-0.52) lower risk of discontinuing breastfeeding compared with not implementing the BFHI. The early stage in BFHI enrolment to begin the “Certificate of Commencement” was associated with a 61% (aHR= 0.39; 95% CI: 0.32-0.48) lower risk of discontinuing breastfeeding compared with not implementing the BFHI. Similarly, accreditation was associated with a 62% (aHR= 0.38; 95% CI: 0.32-0.45) lower risk of discontinuing exclusive breastfeeding compared with not implementing the BFHI. Certification was associated with a 64% (aHR= 0.36; 95% CI: 0.29-0.44) lower risk of discontinuing exclusive breastfeeding compared with not implementing the BFHI. Breastfeeding duration and exclusivity showed improvement after BFHI was implemented regardless the level of designation achieved. The results of this thesis support the implementation of BFHI steps, even in the absence of designation is important and recommend that just implementing the BFHI stepscan improvebreastfeeding outcomes.