School of Public Health

The Baby-Friendly Initiative: Weighing Policy and Evidence

April 2017
Guest Author: Rachel Hays

The U.S. Preventive Services Task Force sparked a discussion among breastfeeding experts about whether system-wide interventions should be reconsidered.
Photo credit: Harald Groven via / CC BY-SA

Supportive maternity care in the hours and days following birth can have a positive effect on breastfeeding success.1 Health organizations across multiple sectors - the Surgeon General, the Centers for Disease Control and Prevention (CDC), and the World Health Organization (WHO) – have called for policy changes so that every mother has access to culturally competent, high quality care and an equal opportunity to breastfeed.2-4

The Baby-Friendly Hospital Initiative (BFHI), established by WHO and the United Nations Children’s Fund, is an international program that helps birthing facilities to encourage breastfeeding and lactation through support and recognition. The program is based on The Ten Steps to Successful Breastfeeding,  a set of evidence-based practices that have been shown to increase breastfeeding initiation and duration.5-6

Although the program is more than 25 years old, it has become increasingly popular in over the past several years. In 2007, fewer than 2% of U.S. babies were born in hospitals with a Baby-Friendly designation. By 2016, that number rose to 18 percent.7,8


The Baby-Friendly designation is a process that begins when a hospital or birth center registers with the not-for-profit Baby Friendly USA.  Facilities pay a “phase fee” as they move through the 4-D pathway to Baby-Friendly Designation. Most facilities spend about one year in each of the four phases – Discovery, Development, Dissemination, and Designation. Baby-Friendly status is conferred upon completion of all phases, the implementation of the Baby-Friendly Guidelines and Evaluation Criteria, and passing an on-site assessment. There are currently 420 U.S. hospitals and birthing centers designated Baby-Friendly.9

Baby-Friendly USA's Ten Steps to Successful Breastfeeding

  1. Have a written breastfeeding policy that is routinely communicated to all healthcare staff
  2. Train all healthcare staff in the skills necessary to implement this policy
  3. Inform all pregnant women about the benefits and management of breastfeeding
  4. Help mothers initiate breastfeeding within one hour of birth
  5. Show mothers how to breastfeed and how to maintain lactation even if they are separated from their infants
  6. Give infants no food or drink other than breast-milk unless medically indicated
  7. Practice rooming-in to allow mothers and infants to remain together 24 hours a day
  8. Encourage breastfeeding on demand
  9. Give no pacifiers or artificial nipples to breastfeeding infants
  10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center


When the U.S. Preventive Services Task Force (USPSTF) published their updated evidence review on breastfeeding promotion last fall they continued to recommend providing interventions during pregnancy and after birth to support breastfeeding but noted that systemic efforts, such as the BFHI, were outside its scope. In the full evidence report written by members of the USPSTF team, the authors concluded there was “limited mixed evidence of an association between system-level interventions and rates of breastfeeding from well-controlled studies.”10,11 An accompanying editorial in the Journal of the American Medical Association (JAMA) argued that clinician breastfeeding promotion efforts should be focused on individuals and that system-wide interventions, specifically BFHI, “be reconsidered until good-quality evidence emerges that these interventions are safe and effective.”12

A public rebuttal from proponents of Baby-Friendly appeared less than a month later on the Breastfeeding Medicine blog. In it, the authors refer to the USPSTF’s evidence report as a “weak literature review” and cite several additional observational and before-and-after studies as evidence that the BFHI increases breastfeeding rates. They point out that the two studies included in the report show that the BFHI positively impacted breastfeeding rates among less educated mothers.

Furthermore, they advocate for the acceptance of randomized trials that have been conducted, even if they took place outside the United States. “They excluded the world’s largest randomized study of Baby-Friendly,” they wrote, “because it was conducted in Belarus and not in a high-income country.” The Promotion of Breastfeeding Intervention Trial (PROBIT) was published in JAMA in 2001 and showed that exclusive breastfeeding at 3 months went from 6% to 43% at facilities which used a Baby-Friendly type intervention.13

Two of the original authors of the USPSTF report countered in JAMA: “We set a priori eligibility criteria limiting included study designs to randomized clinical trials, prospective cohort studies, and before-and-after designs with concurrent control groups.” The pair explained that PROBIT was intentionally omitted because they believe Belarus facilities not to be comparable to current U.S. medical facilities.14

Baby-Friendly Births in Region X 2007 2011 2016
Alaska 0% 21.3% 29.3%
Idaho 6.1% 7% 6.6%
Oregon 6.3% 8% 32.4%
Washington 8.9% 9.7% 11.5%

The debate over the strength of the evidence continues while the number of Baby-Friendly designated facilities rises alongside national breastfeeding rates.7 Since the publication of the USPSTF report last October, 37 additional facilities were registered as Baby-Friendly, for a total of 420 Baby-Friendly hospitals in the United States. 9

Therefore, as more and more babies are born in Baby-Friendly facilities, we should continue to add to the body of evidence and evaluate the BFHI and its components to ensure that women and their families are receiving high-quality, culturally competent care and an equal opportunity to breastfeed. Going forward, the authors of the full evidence report called for more longitudinal, controlled design studies to further explore BFHI and for whom and to what extent it increases breastfeeding rates.14

Guest author, Rachel Hays, earned her master’s degree in Health Services from the University of Washington’s School of Public Health in June 2017. Her background and area of study include breastfeeding, paraprofessional interventions, the Baby-Friendly Hospital Initiative, cultural competency, health policy, children and youth with special health care needs, and program evaluation.


  1. Raphael, Dana. The Tender Gift: Breastfeeding. Englewood Cliffs, NJ: Prentice-Hall; 1973.
  2. Office of the Surgeon General (US), Centers for Disease Control and Prevention (US), Office on Women's Health (US). The Surgeon General’s Call to Action to Support Breastfeeding. Office of the Surgeon General (US); 2011. Accessed March 28, 2017.
  3. Center for Disease Control and Prevention. Strategies to Prevent Obesity and Other Chronic Diseases: The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies. Accessed March 28, 2017.
  4. World Health Organization. Young Child Feeding Global Strategy for Infant and Child. Singapore; 2003. Accessed March 28, 2017.
  5. UNICEF. Baby-Friendly Hospital Initiative; 2002. Accessed March 28, 2017.
  6. The Ten Steps to Successful Breastfeeding. Baby-Friendly USA. 2017. Accessed March 28, 2017.
  7. Centers for Disease Control and Prevention. Breastfeeding Report Card—United States, 2007.; 2007. Accessed March 28, 2017.Centers for Disease Control and Prevention (CDC) NC for CDP and HP.
  8. Breastfeeding Report Card— United States, 2016. 2016. Accessed April 6, 2017.
  9. Baby-Friendly USA. Accessed March 28, 2017.
  10. Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Primary Care Interventions to Support Breastfeeding: US Preventive Services Task Force Recommendation Statement . JAMA. 2016;316(16):1688. doi:10.1001/jama.2016.14697.
  11. Patnode CD, Henninger ML, Senger CA, Perdue LA, Whitlock EP, JM S. Primary Care Interventions to Support Breastfeeding: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2016;316(16):1694. doi:10.1001/jama.2016.8882.
  12. Flaherman V, Von Kohorn I, CD P, et al. Interventions Intended to Support Breastfeeding. JAMA. 2016;316(16):1685. doi:10.1001/jama.2016.15083.
  13. Bartick M, Nickel N. Evidence is Clear: Baby-Friendly Hospital Initiative Increases Breastfeeding Rates in the US and Closes Breastfeeding Disparities | Breastfeeding Medicine. Breastfeeding Medicine. Published 2016. Accessed March 28, 2017.
  14. Patnode CD, Senger CA, B C, ED H, EP W. Evidence for the Baby-Friendly Hospital Initiative to Support Breastfeeding—Reply. JAMA. 2017;317(7):771. doi:10.1001/jama.2016.20835.