Does the BFHI enhance breastfeeding?
		Commonly Asked Questions and Answers
		Simple things you can do to promote breastfeeding in your community
		Links for Breastfeeding Advocates

Yes! Data from around the world clearly indicates the positive impact of implementation of the Ten Steps to Successful Breastfeeding on breastfeeding initiation, duration, exclusivity, and related child health outcomes.

Data collection regarding the impact of the BFHI on breastfeeding rates in the US has just begun. Here are some of the highlights of studies published to date:

	Researchers at Boston Medical Center, the nation’s 22nd Baby-Friendly hospital, have reported that during the implementation of the BFHI, breastfeeding rates rose from 58 percent to 87 percent, including an increase among US-born African-American mothers from 34 percent to 74 percent in 1999. [Philipp BL et al. 2001. Baby-Friendly Hospital Initiative Improves Breastfeeding Initiation Rates in a US Hospital Setting. Pediatrics 108(3):677-681.]
	Researchers from federal agencies surveyed the exposure of more than a thousand women to five of the Ten Steps. They found that only 7 percent of mothers surveyed experienced all five steps measured. Mothers who experienced none of the steps were nearly eight times more likely to discontinue breastfeeding before 6 weeks postpartum. The more steps that mothers experienced, the greater the likelihood of continuation of breastfeeding at and beyond 6 weeks postpartum. The strongest risk factors for early breastfeeding termination were late breastfeeding initiation and supplementation of the baby. [DiGirolamo AM, LM Grummer-Strawn, S Fein. 2001. Maternity care practices: implications for breastfeeding. Birth 28:94-100.]

UNICEF has collected highlights of the outcomes of implementing the BFHI in a range of countries around the world. Findings include:

	UNICEF estimates that more than one million health care providers worldwide have been trained through the program
	In China, after two years of BFHI implementation, exclusive breastfeeding rates doubled in rural areas and increased from 10 percent to 47 percent in urban areas
	In Nicaragua, breastfeeding rates have increased from 47 percent prior to implementation of the BFHI to nearly 100% in 1999
	In Poland, between 1995 and 1998, implementation of the BFHI resulted in an increase of rooming-in from 19 percent to 60 per cent, and the practice of supplementing breastfed infants fell from 54 percent in 1988 to 22 per cent in 1998
	In Zambia, implementation of the BFHI is credited with a rise in the exclusive breastfeeding rate of from 16 percent in 1992 to 35 percent in 1997
	[UNICEF, Programme Division. 1999. Baby-Friendly Hospital Initiative: Case studies and progress reports. New York: UNICEF.]

A large randomized controlled trial (PROBIT) was conducted in the Republic of Belarus. The PROBIT trial examined the outcome of implementation of the Ten Steps to Successful Breastfeeding in thirty-one Belarussian maternity units and clinics. Infant health outcomes were tracked for one year. The results were that infants born in the intervention sites (where the Ten Steps were implemented) were significantly more likely than control infants to be breastfed to any degree at 12 months, were more likely to be exclusively breastfed at 3 months and 6 months, and had a significant reduction in the risk of 1 or more gastrointestinal tract infections and of atopic eczema. [Kramer MS et al. 2001. Promotion of Breastfeeding Intervention Trial (PROBIT): A randomized trial in the Republic of Belarus. JAMA 285:413.]

The impact of the BFHI on maternal health has yet to be quantified, but experts anticipate that exposure to Baby-Friendly practices will be found to improve maternal health outcomes as well.

How does the Baby-Friendly process work?
Baby-Friendly USA is pleased to announce the new “4-D Pathway” for achieving the Baby-Friendly Designation.  This new method organizes the process into manageable and achievable tasks. There are four phases to the pathway.  First, in the Discovery Phase, a birthing facility commits to the Baby-Friendly process by submitting an application (including a letter from the CEO indicating support, a fee and a completed self-appraisal tool) to Baby-Friendly USA.  After that, the facility works through the Development, Dissemination and Designation Phases, accessing technical assistance from Baby-Friendly USA and receiving feedback on submitted policies, curricula, etc.  Finally, the facility requests an on-site assessment by the Baby-Friendly assessment team and a review by the External Review Board. Upon successful completion of this review process, the "Baby-Friendly" designation is conferred. If the facility does not pass on first assessment, it may apply for reassessment when identified problems have been rectified.

Our facility is currently registered with Baby-Friendly USA and participating in the current Certificate of Intent program.  Are we required to go into the new 4-D Pathway?
Facilities that have a current Certificate of Intent (COI) by April 1, 2010 have the following options:

1. Move into the new 4-D Pathway to Designation Program
2. Complete the COI Program by December 31, 2011.  (Have satisfied pre-assessment requirements and have secured an on-site assessment slot) After December 31, 2011 the COI pathway is closed.  All facilities will be moved into the Pathway program.
3. If option 2 is initially selected, facilities may to transition to the 4-D Pathway at anytime.

What if my hospital or birthing center is not "Baby-Friendly" enough to get started?
There is no such thing. The Pathway process provides an easy to follow framework for your effort to become a Baby-Friendly facility.  A facility does not have to answer "yes" to all questions on the Self-Appraisal Tool to obtain a certificate of intent.

Are there any charges for the process?
Yes. Each hospital or birth center is assessed an annual fee. Please see fee schedule for more information. In addition there are optional services, support materials and videos available for a charge.  The fee includes a number of hours of technical support, reviews of materials and access to a discussion list.  Once a hospital has achieved Baby-Friendly status, a smaller annual fee is assessed.

What are the costs for the assessment?
Facilities in the 4-D Pathway are charged for travel costs, lodging and per diem for two assessors.

Where does the funding for the Baby-Friendly program come from?
The funds to run the Baby-Friendly USA office and programs come from fees paid by birth facilities and from the contributions of interested individuals and organizations. Baby-Friendly USA does not accept contributions of any type from companies in violation of the International Code of Marketing of Breast-Milk Substitutes. 

My hospital is part of a three hospital system. Can the whole system make one application for the pathway to designation?
No. Each hospital within a system has its own unique assets and challenges regarding breastfeeding promotion, protection and support. Each hospital must be assessed on its own merit.

Are the US Ten Steps the same as the global?
Yes, except Step 4 for the US is written that breastfeeding should be initiated in the first hour of life in the U.S., as opposed to the first half-hour elsewhere.  In both the US and global 10 steps, the baby should be placed skin-to-skin immediately after birth and remain there continuously until the completion of the first breastfeeding.  Also, in the US we have interpreted Step 6 "Give newborn infants no food or drink other than breast milk, unless medically indicated," as "Give breastfed newborns....."

What about purchasing formula? Must my hospital purchase all formula used to pass?
Yes.   The Baby-Friendly Hospital Initiative supports the International Code on the Marketing of Breast-milk Substitutes ("WHO Code"). The WHO Code stipulates that health care facilities and professionals neither accept nor offer free or low-cost substitutes for human milk. In keeping with the Code, the Baby-Friendly Hospital Initiative asks facilities to purchase all infant formula in the same manner as it purchases all other supplies. Additionally, facilities should not give infant formula samples, literature, or other items bearing the name of an infant formula product to breastfeeding mothers.

Step two says "train all staff." Our physicians on staff are not technically employees of the hospital. Do they have to be trained?
Yes. The External Review Board, composed of knowledgeable experts in the fields of medicine, public health, and nursing, have determined that any pediatrician, obstetrician, or family practice physician with a practice including breastfeeding families who has staff privileges at a hospital or birthing center must be trained in the advantages and management of breastfeeding. The amount and content of training offered may be tailored to needs of different professionals.  For example, nursing staff with primary responsibility for helping mothers initiate breastfeeding should have, at minimum, 20 hours of training as identified by UNICEF. Physicians must have a minimum of 3 hours training.

Our hospital is thinking about becoming Baby-Friendly. How soon can we be assessed?
First, your hospital will need to enter the Pathway to Baby-Friendly Designation and complete all of the tasks in the 4 D Phases – Discovery, Development, Dissemination and Designation before the readiness interview.  After a successful readiness interview, an on-site assessment can be scheduled.

When can we use the terminology of "Baby-Friendly Hospital?"
Only when your facility has been assessed, approved by the External Review Board, and the CEO has received the letter from the External Review Board. Use of the trademarked term "Baby-Friendly" is restricted only to fully designated facilities.

Why should our facility consider becoming a Baby-Friendly facility?
The Baby-Friendly Designation is the globally recognized symbol of world-class maternity care.  In addition, the pathway to designation provides facilities the opportunity to:

• deliver patient-centered care
• improve health outcomes for mothers and babies
• improve patient satisfaction
• increase market share
• elevate the reputation and standards of the birthing facility
• enhance a professional environment of competence
• demonstrate a commitment to quality improvement
• build leadership and team skills among staff
• improve m-PINC scores as rated by the Center for Disease Control
• meet Joint Commission maternity care standards for exclusive breast milk feeding
• meet corporate compliance requirements
• lead the way to achieving Healthy People 2020 goals for breastfeeding
• become a member of an exclusive group of elite facilities around the world who have achieved this globally prestigious award

	Smile at every mother you see breastfeeding, and give her a “thumbs up.” If the situation permits, compliment her on her choice to breastfeed and/or comment on how wonderful it is to see a mother breastfeeding
	Thank the management of eating establishments, stores, and public facilities that treat breastfeeding mothers and babies with respect
	Check to see if the place of worship, club, gym, library, and other gathering places you regularly attend is supportive of women who breastfeed. Find out if a place is provided for mothers to comfortably nurse their babies. If improvements are needed, help them to understand how breastfeeding benefits the whole community
	Donate a book or video on breastfeeding to your local public library. Suggest other materials on breastfeeding for the library to purchase
	Ask if local programs for pregnant teens offer information on breastfeeding. If not, suggest the program contact a local La Leche League Leader, International Board Certified Lactation Consultant or other breastfeeding specialist for help in setting up a perinatal breastfeeding support program
	Take a look at the health, nutrition, and child care materials offered by your school district to see if breastfeeding is included. Suggest to the school board, principals, and teachers of relevant classes that accurate information on breastfeeding is important to future parents
	Look around health care waiting rooms to see if there are breastfeeding materials produced by infant formula manufacturers. When the health care provider recommends breastfeeding, the presence of these materials sends a mixed message to new parents
	Encourage your local hospital(s) and birth center(s) to join the Baby-Friendly Hospital Initiative
	Call your health insurance company and ask what services they cover for breastfeeding mothers and babies. Encourage expanded coverage for breastfeeding-related services
	Ask any group of which you are a member to schedule a presentation on “how breastfeeding benefits the community” as a topic of discussion or speech. Local La Leche League Leaders and International Board Certified Lactation Consultants can help you locate an appropriate speaker
	Before giving to a hunger campaign, find out if they support breastfeeding Write to the organization suggesting that breastfeeding is an essential key to solving the problem of hunger
	Join others in your community in the celebration of World Breastfeeding Week, held annually August 1-7. Look for local activities and events in which to participate

Adapted from “Did You Know Breastfeeding Makes a Difference?” written by La Leche League, the International Lactation Consultant Association, and the National Alliance for Breastfeeding Advocacy.