10 Things You Need to Know About Baby-Friendly Hospitals

In the U.S., 30% of babies are born in baby-friendly hospitals, and we have around 600 in total here. But what does “baby-friendly” even mean?

Baby-friendly simply means “breastfeeding friendly,” and if a hospital is certified as baby-friendly, this means they must follow the “10 Steps to Successful Breastfeeding” that is outlined and awarded by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF).

The Baby-Friendly philosophy includes:

Human milk is optimal for human babies to be nurtured and nourished.
The first few days in the birth facility should be protected as a time of bonding and support, not influenced by commercial interests.
And every mother should be informed of the importance of breastfeeding and respected to make her own decision [1].

Baby-Friendly Hospitals: How to Receive the Designation:

First, be aware that the “Baby-Friendly” designation is difficult to get and keep and requires a financial commitment by the hospital.

Additionally, as a baby-friendly hospital or maternity facility, they are required to:

Follow the Ten Steps to Successful Breastfeeding
Pay fair market value for infant formula and formula products
Be compliant with ‘the Code.’

What is ‘the Code’ for Baby-Friendly Hospitals?

The Code, also known as the World Health Organization’s International Code of Marketing of Breastmilk Substitutes, includes:

No advertising of breastmilk substitutes (mostly formula), bottles, or teats (an artificial nipple for bottle-feeding infants) to the public
Nor free samples (of formula) for mothers
No promotion of these products in healthcare facilities
Nor contact between marketing personnel and mothers.
No gifts or personal samples to health workers
No words or pictures idealizing artificial feeding, including pictures of infants on the products
Information to health workers should be scientific and factual
All information on artificial feeding, including the labels, should explain the benefits of breastfeeding and the costs and hazards associated with artificial feeding.
Unsuitable products, such as condensed milk, should not be promoted to babies.
All products should be of high quality and take account of the climate and storage conditions of the country where they are used.

Note: The Code does not apply to pumps, breastmilk storage bags, or pacifiers. Check out my post on “Should your Baby Use a Pacifier?” to access the evidence-based pros and cons of pacifier use for your little one!

Essentially, following the Code decreases the promotion of bottle and formula feeding and how quickly formula is given out, forcing healthcare workers in baby-friendly settings to evaluate if formula use is really medically necessary.

The 10 Steps to Successful Breastfeeding in Baby-Friendly Hospitals

To be a certified baby-friendly hospital, the hospital must follow these 10 steps:

1. Written breastfeeding policy that is routinely communicated to all healthcare staff in baby-friendly settings

This step focuses on ensuring all maternal and baby health care staff supports and promotes mothers to breastfeed by:

Not promoting infant formula, bottles, or pacifiers
Making breastfeeding care standard practice
Keeping track of support for breastfeeding

2. Ensure that staff have sufficient knowledge, competence, and skills to support breastfeeding and implement these policies

Staff in baby-friendly hospitals are trained in supporting mothers in breastfeeding. This is crucial to avoid nurses who aren’t trained in breastfeeding thoroughly enough to give parents tools and conclusions to problems they may face while still in the hospital.

Furthermore, this ensures that health care workers’ knowledge and skills will be assessed because it is important that mothers and parents receive appropriate and up-to-date breastfeeding support.

3. Inform all pregnant women about the benefits and management of breastfeeding

Health care professionals in a baby-friendly hospital will tell you the benefits of breastfeeding for mom and baby, which are truly impeccable, and I can’t believe I didn’t know them when I had my first daughter!

Topics to be covered include the benefits of breastfeeding, the importance of exclusive breastfeeding, breastfeeding management (such as skin-to-skin contact, rooming-in, and feeding cues), possible effects of analgesia/anesthesia on infant behavior, and the available non-pharmacologic pain relief.

4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible (within the first hour of birth)

This step includes encouraging skin-to-skin between mother and baby as soon as possible after birth. During skin-to-skin, the mothering hormone (prolactin), which facilitates breastfeeding, increases the bond between you and your baby increases, plus many more benefits!

Skin-to-skin following birth is referred to as the “golden hour,” a special time for mom and baby to have skin contact. However, if you received labor pain medication, your baby should receive 2 hours of skin-to-skin contact for the baby to be able to self-attach to your breast. This extra time is needed because labor pain medications may make your baby more sleepy (but not always!) [4].

Some mothers may also need help comfortably latching and positioning their baby at their breast, which is when a trained nurse or provider in this setting would be needed.

5. Show mothers how to breastfeed and how to maintain lactation, even if separated from their baby

The purpose of step #5 is to ensure ongoing breastfeeding assessment, evaluation, and support during the stay.

This includes checking positioning, attachment, and suckling. Plus giving positive and practical breastfeeding support and helping mothers with some common breastfeeding problems.

6. Do not give breastfed newborns any food or fluids other than breastmilk unless medically necessary

With the baby-friendly certification, hospitals will support mothers to breastfeed by only supporting breastfeeding unless there are medical reasons to supplement with something else.

If supplementation is needed, donor breast milk should always be the first choice, and then formula. And if formula is used, the parents should be educated on correctly preparing formula for their new baby.

7. Enable mothers and infants to remain together and practice rooming 24 hours a day

This ensures that healthy moms and babies have opportunities for skin-to-skin contact and that mothers learn early about the baby’s feeding cues.

Nevertheless, if there are ever concerns about the mother or the infant, then appropriate measures are expected to be taken to ensure quality care which may mean the baby needs to go to the Nursery to be assessed and/or watched more closely.

Check out the evidence-based benefits of rooming in with your baby versus keeping your baby in the hospital nursery.

8. Encourage mothers to recognize and respond to their baby’s hunger cues (feeding on-demand/responsive feeding)

To encourage responsive feeding, a health care worker will educate the mother on how to read her baby’s hunger and fullness cues to respond to her baby appropriately rather than timing and spacing out feedings.

Hunger cues include:

Rooting
Active alert state (Baby may be fussy, irregular breathing, indicates your baby is starting to need something)
Flexing arms/legs, clenching hands
Sucking motions
Sucking on finger or fist (Also, a normal developmental milestone around 3 months old so look for more than this around that time)
Crying (late cue)

9. Counsel mothers on the benefits and risks of bottle-feeding, teats, and pacifiers

Instead of receiving bottles or pacifiers, mothers are counseled on the benefits and risks of babies using bottles and pacifiers. Check out Should Your Baby Use a Pacifier?

10. Coordinate discharge so that parents and their infants have timely access to ongoing support and care

This is such a fantastic yet overlooked way to support a mama who just had a baby and is figuring out breastfeeding. This includes fostering the establishment of breastfeeding support groups and refer mothers to them upon discharge from the hospital.

Additionally, this can include a lactation consultant’s information to help the new mother on her breastfeeding journey.

Do Baby-Friendly Hospitals Work?

The PROBIT Trial is a prospective, cluster-randomized trial done in hospitals and polyclinics in the Republic of Belarus. 16 sites implemented the 10-steps to successful breastfeeding and 15 sites continued their usual infant feeding practices.

Infants born at the 10-step intervention sites:

Mothers are more likely to meet their breastfeeding goals at 1 month [7]
Were significantly more likely to be exclusively breastfed at 3 months and 6 months old [5]
Were significantly more likely to breastfeed to any degree at 12 months old [5]
Had fewer gastrointestinal (GI) infections [5]
Had less atopic eczema [5]

Children born at the 10-step intervention sites at the age of 6.5 from this trial had:

6 points higher IQs [5]
Academic ratings are higher for both reading and writing [5]

Children at 11.5 years old had a reduction in problematic eating attitudes in areas where breastfeeding was promoted via the Baby-Friendly Hospital Initiative, PROBIT intervention [6].

“There is substantial evidence that implementing the Ten Steps significantly improves breastfeeding rates. A systematic review of 58 studies on maternity and newborn care published in 2016 demonstrated clearly that adherence to the Ten Steps impacts early initiation of breastfeeding immediately after birth, exclusive breastfeeding, and total duration of breastfeeding.” [3].

Conclusion on Baby-Friendly Hospitals:

The PROBIT Trial proved that the implementation of the Baby-Friendly Hospital Initiative may be the “fast track” option to a foundation of enhanced public health!

If you’re motivated and planning on breastfeeding your baby, I highly recommend looking into a baby-friendly hospital near you.

I personally believe all of these practices should be standard at all hospitals, so I’m hoping our number of baby-friendly hospitals will continue to rise. Some other countries worldwide are doing much better than the U.S. with this aspect, with more than 20,000 baby-friendly hospitals in 150 countries around the world!

What do you think about the 10 steps to successful breastfeeding? What was your experience in a baby-friendly hospital or one that wasn’t? I’d love to hear your thoughts below!

Sources:

[1] The Baby-Friendly Hospital Initiative

[2] Number of babies born in baby-friendly hospitals

[3] WHO- Ten steps to successful breastfeeding

[4] Lind JN, Perrine CG, Li R. Relationship between use of labor pain medications and delayed onset of lactation. J Hum Lact. 2014;30(2):167-173. doi:10.1177/0890334413520189

[5] Kramer MS, Chalmers B, Hodnett ED, Sevkovskaya Z, Dzikovich I, Shapiro S, Collet JP, Vanilovich I, Mezen I, Ducruet T, Shishko G, Zubovich V, Mknuik D, Gluchanina E, Dombrovskiy V, Ustinovitch A, Kot T, Bogdanovich N, Ovchinikova L, Helsing E; PROBIT Study Group (Promotion of Breastfeeding Intervention Trial). Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus. JAMA. 2001 Jan 24-31;285(4):413-20. doi: 10.1001/jama.285.4.413. PMID: 11242425.

[6] Effects of promoting longer-term and exclusive breastfeeding on childhood eating attitudes: a cluster-randomized trial

[7] Jennifer L. Beauregard, Jennifer M. Nelson, Ruowei Li, Cria G. Perrine, Heather C. Hamner; Maternity Care Practices and Breastfeeding Intentions at One Month Among Low-Income Women. Pediatrics April 2022; 149 (4): e2021052561. 10.1542/peds.2021-052561

DISCLAIMER: This post is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding you or your baby’s health. Please read my Medical Disclaimer for more info