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?
There are three major steps to the process. First, a birthing facility commits to the Baby-Friendly process by submitting an application (including a letter of intent, an annual fee and a completed self-appraisal tool) to Baby-Friendly USA. After receipt of a Certificate of Intent, the facility works toward the full implementation of all ten steps, accessing technical assistance from Baby-Friendly USA staffers as needed. Finally, the facility requests an on-site assessment by the Baby-Friendly survey 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.

What if my hospital or birthing center is not "Baby-Friendly" enough to get a Certificate of Intent?
There is no such thing. The Certificate of Intent only signifies the commitment to work at becoming 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 (currently ranging from $550 - 900), based upon number of births in the previous calendar year. In addition there are optional support materials and videos available for a charge. The annual fees are used to support the program, so that Baby-Friendly USA can provide technical support, produce a newsletter and publicize the program through newsletters, conference exhibits, etc. Once a hospital has achieved Baby-Friendly status, a smaller annual fee is assessed.

What are the costs for the assessment?
The fees for assessment in 2006 are $3,000 plus 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 groups. Baby-Friendly USA does not accept contributions of any type from companies in violation of the World Health Organization's 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 a Certificate of Intent?
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, where breastfeeding should be initiated in the first hour of life in the U.S., as opposed to the first half-hour elsewhere. 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 World Health Organization 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 WHO 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, 18 hours of training as identified by UNICEF. Physicians must have a minimum of 3 hours training. Other staff members should have a level of training appropriate to their workplace exposure to breastfeeding mothers and children.

Our hospital is applying for a Certificate of Intent. How soon can we be assessed?
Hospitals and birth centers indicate their readiness for assessment by responding to semi-annual check-ins. Follow-up phone calls will be made to those who indicate readiness. Priority for assessment is given to facilities that have held Certificates for more than one year.

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?
For many reasons! First, for the health of our most vulnerable citizens - our babies. Full implementation of the Ten Steps benefits all babies - even those who are not breastfed - by improving mother-baby contact and education. Hospitals are also finding that women who are well supported in vulnerable postpartum period are likely to become long-term clients of the hospital, referring other family members and peers to the facility.

	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.