Intended for healthcare professionals


Breast feeding: the baby friendly initiative

BMJ 1998; 316 doi: (Published 23 May 1998) Cite this as: BMJ 1998;316:1548

Must adapt and develop to succeed

  1. Aeesha N J Malik, Medical student,
  2. William A M Cutting, Reader
  1. University of Edinburgh, Department of Child Life and Health, Edinburgh EH9 1UW

    Breast feeding is unparalleled in providing an infant with ideal nourishment, protection from infections, and much more.1 2 Despite this, there is still a strong culture for bottle feeding in Britain.3 The global baby friendly hospital initiative, known in Britain as the baby friendly initiative, was launched jointly by UNICEF and the World Health Organisation in 1991. The objective was to reverse the negative impact that many maternity hospital practices have on establishing breast feeding. The “ten steps” (see box) are intended as a standard for good practice.4 The “Baby Friendly Initiative Golden Award” is given to hospitals that complete the 10 steps and achieve a 75% rate of breast feeding on discharge, and the British “Baby Friendly Initiative Award” to hospitals that achieve a 50% breast feeding rate on discharge. By December 1996 there were only three baby friendly hospitals in Britain and another 10 that had a certificate of commitment (for achieving steps 1, 7, and 10).

    The “ten steps” to successful breast feeding

    Step 1. Have a written breast feeding policy that is routinely communicated to all healthcare staff

    Step 2. Train all healthcare staff in the skills necessary to implement this policy

    Step 3.Inform all women (face to face and leaflets) about the benefits and management of breast feeding

    Step 4. Help mothers initiate breast feeding within half an hour of delivery

    Step 5. Show mothers how to breast feed and how to maintain lactation (by expressing milk) even if they should be separated from their infants

    Step 6. Give new born infants no food or drink unless “medically” indicated. No promotion of formula milks

    Step 7. Practise “rooming-in.” All mothers should have their infant cots next to them 24 hours a day

    Step 8. Encourage breast feeding on demand

    Step 9. Give no artificial teats or pacifiers to breast feeding infants

    Step 10. Foster the establishment of breast feeding support groups and refer mothers to them

    Vallenas C, Savage-King F. Evidence for the ten steps to successful breastfeeding. Geneva: WHO Child Health and Development Unit, 1997.

    Why have hospitals been slow to take up this initiative? Firstly, there is little government involvement in Britain, unlike in developing countries. In fact, the British government provides more financial support to poor mothers who choose to bottle feed than those who breast feed.5 Secondly, an emphasis on consumers' right to choose makes some health professionals wary of stressing the benefits of breast feeding for fear of making bottle feeding mothers feel guilty.3 This is not an issue in the developing world, where breast feeding is the only realistic option for most mothers. Thirdly, a mother discharged early from hospital in Britain may be isolated from her extended family, have only limited support from a community midwife, and find it difficult to cope with breast feeding on her own in a social environment generally hostile to breast feeding.

    These differences mean that the baby friendly initiative must be adapted, and developed if it is to progress in Britain. As a first step, the baby friendly initiative should be introduced to the whole primary care team and not confined to hospitals. The critical period when mothers, especially those with their first babies, need the most help spans the few days in hospital and the subsequent week. Extending training to general practitioners, community midwives, and health visitors would ensure that everyone working with the mothers, both outside and inside hospitals, had the same up-to-date knowledge of breast feeding and its advantages. Better coordination with existing breast feeding networks such as the National Childbirth Trust would also give mothers more support. Finally, imaginative use of the media to promote breast feeding might reach more mothers in their teens and 20s.

    Most hospitals in Britain have breast feeding policies that include at least some of the 10 steps, and awareness about breast feeding continues to grow. The baby friendly initiative, where it operates, creates a hospital environment in which breast feeding is the accepted norm and mothers are at least given the information they need to make a choice. Remaining problems in some hospitals include inappropriate use of supplemental feeding, advertising of milk formulas, poor teaching of the benefits of breast feeding, and the continuing practice of separating mothers from their babies (R Balendra, unpublished data).6 8

    How can we judge a hospital's efforts to promote breast feeding? In a country where most women are discharged within three days of giving birth it is probably misleading to compare breast feeding rates at discharge: they may give a falsely low impression of the number of women who eventually establish breast feeding. Rates at babies' first immunisation two months later would give a more accurate picture. Furthermore, most mothers have decided how they are going to feed their baby long before they reach hospital, influenced by cultural and economic factors outside the hospitals' control. 3 6 Hospitals should not be demoralised by setting breast feeding targets that are unachievable. This is particularly important in communities where rates are low and encouragement most needed.

    The main aim of the baby friendly initiative is to make it easier for mothers to breast feed. Government and NHS managers should recognise and encourage its development. The initiative could be, for example, an issue in the patient's charter or an indicator of quality in audit. The current emphasis on maternity services gives structure to the promotion of breast feeding in hospital, but it should not end there. A stronger initiative focused on the needs of women in Britain could be a useful bridge between community teams and their hospitals.


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