Evaluating the impact of the Baby-Friendly Hospital Initiative on breast-feeding rates: a multi-state analysis

Steady gains in breast-feeding initiation and duration among US mothers have resulted in the highest levels of breast-feeding seen in over 30 years(1,2). Although 77 % of mothers are initiating breast-feeding, only 16 % are achieving the American Academy of Pediatrics’ recommendation of exclusive breast-feeding for the first 6 months(2,3). Moreover, racial and socio-economic disparities persist(1,4–6); black mothers are less likely to start and continue breast-feeding than white and Hispanic mothers(5,6). Lower maternal education is also one of the strongest predictors of not initiating breast-feeding and early discontinuation(5,7,8). Current US practices to promote breast-feeding are not ideal. The 2011 US Surgeon General’s Call to Action to Support Breastfeeding identified hospital policies and clinical practices as important barriers for many women to successfully start breast-feeding and continue after discharge(5). Results from the survey of Maternity Practices in Infant Nutrition and Care (mPINC) conducted by the Centers for Disease Control and Prevention in 2011 indicated that the average score for US hospitals and birth centres was 70 out of 100 points on a measure of practices to support breast-feeding(9). The US Surgeon General’s report listed implementation of the Baby-Friendly Hospital Initiative (BFHI) as the first strategy to achieve the goal of ensuring that maternity care practices are fully supportive of breast-feeding(5). The BFHI was established by the WHO and UNICEF in 1991 and evidence-based guidelines, Ten Steps to Successful Breastfeeding, were published to promote, protect and support breast-feeding within the birth facility and after(10,11). While more than 20000 hospitals and birth centres in 156 countries had been designated as Baby-Friendly by 2009(12), there were only 158 BFHI facilities in the USA as of January 2013(11). Increasing the proportion of US births in facilities that support breast-feeding is a public health priority(3,5,13–15). Despite the breadth of evidence on BFHI internationally(16–22), research in the USA has been limited. The majority of research in the USA has been cross-sectional. Overall, these studies found that more BFHI hospital practices were associated with higher breast-feeding initiation and continuation(7,23–27). Some longitudinal data emanate from a single hospital, Boston Medical Center, an inner-city US hospital serving a predominantly low-income and black population that became Baby-Friendly in 1999. A series of before–after studies has demonstrated increases in breast-feeding initiation(28) and sustained levels of breast-feeding initiation a few years after accreditation(29) as well as breast-feeding rates at 6 months that were consistent with national levels(30). Before–after studies do not include a control group nor do they take into account increases in breast-feeding over time. The only randomized controlled trial of the BFHI has been conducted in Belarus(18), a country with breast-feeding rates and a health-care system that are very different from those in the USA. To overcome the limitations of previous research, we conducted a longitudinal study of the effects of BFHI accreditation on breast-feeding rates over an 11-year period among 25000 mothers giving birth in thirty-two hospitals from five states. Our aim was to evaluate the impact of the BFHI on breast-feeding initiation and duration overall and according to education level.