Education And Debate Quality improvement report

Effect on rates of breast feeding of training for the Baby Friendly Hospital Initiative

BMJ 2001; 323 doi: (Published 08 December 2001) Cite this as: BMJ 2001;323:1358
  1. Adriano Cattaneo, epidemiologist (cattaneo{at},
  2. Roberto Buzzetti, medical statistician the Breastfeeding Research and Training Working Group.b
  1. a Unit for Health Services Research and International Cooperation, Istituto per l'Infanzia, Via dell'Istria 65/1, 34137 Trieste, Italy
  2. b Centre for the Evaluation of Effectiveness and Appropriateness of Health Care (CEVEAS), Modena, Italy
  1. Correspondence to: A Cattaneo
  • Accepted 28 June 2001


Problem: Breastfeeding rates and related hospital practices need improvement in Italy and elsewhere. Training of staff is necessary, but its effectiveness needs assessment.

Context: Eight hospitals in different regions of Italy.

Design: Controlled, non-randomised study. Data collected in three phases. Training after the first phase in group 1 hospitals and after the second phase in group 2.

Strategies for change: Training of trainers and subsequent training of health workers with a slightly adapted version of the 18 hour Unicef course on breastfeeding management and promotion.

Key measures for improvement: Hospital practices, knowledge of 571 health workers, and breastfeeding rates at discharge, three, and six months in 2669 mother and baby pairs.

Effects of change: After training hospitals improved their compliance with the “ten steps to successful breast feeding,” from an average of 2.4 steps at phase one to 7.7 at phase three. Knowledge scores of health professionals increased from 0.41 to 0.72 in group 1 (training after phase one) and from 0.53 to 0.75 in group 2 (after phase two). The rate of exclusive breast feeding at discharge increased significantly after training: 41% to 77% in group 1 and 23% to 73% in group 2, as did the rates of full (exclusive plus predominant) breast feeding at three months (37% to 50% in group 1 v 40% to 59% in group 2) and any breast feeding at six months (43% to 62% in group 1 v 41% to 64% in group 2).

Lessons learnt: Training for at least three days with a course including practical sessions and counselling skills is effective in changing hospital practices, knowledge of health workers, and breastfeeding rates.


  • Funding Istituto per l'Infanzia, IRCCS Burlo Garofolo, Trieste, and from the Associazione Culturale Pediatri.

  • Competing interests None declared.

  • Accepted 28 June 2001
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