The BFHI~Setting the Stage for Successful Breastfeeding

by Asheya on June 3, 2012

In 1991, the Breastfeeding Friendly Hospital Initiative was created.  In 1990 the Innocenti Declaration  was developed by the WHO and UNICEF, a document that outlines the optimal feeding of babies and children.  Part of this declaration was a recommendation that all governments should develop national breastfeeding policies and implement systems to protect, promote, and support breastfeeding.  Further to this, the following year the WHO and UNICEF developed the Baby Friendly Hospital Initiative.  This initiative is based on research that determines which activities are most likely to undermine the establishment of healthy breastfeeding relationships between women and their babies, and how to minimize these detrimental activities.  It is also based on research which determines which activities are most likely to support the establishment of healthy breastfeeding relationships, and how to implement these activities into our hospitals, maternity wards, and society.  The goal of the Baby Friendly Hospital Initiative is to improve health by raising breastfeeding success rates.

Some families will choose not to breastfeed.  Some families cannot breastfeed.  This is okay!  The BFHI is not intended to exert pressure on individuals or reduce womens’ choice when it comes to bodily autonomy.  It is intended to help provide an optimal environment for establishing breastfeeding for those families who want to.  The most difficult and heartbreaking situations are those in which women want to breastfeed and try, but are not able to succeed.  Particularly for reasons which are preventable or based on a lack of accurate information.

Since the beginning of the Baby Friendly Hospital Initiative, over 15,000 hospitals worldwide have become designated “Baby Friendly.”  In order to be designated as Baby Friendly, a hospital must implement the following ten steps, and receive accreditation from an official United Nations BFHI representative:

1.  Have a written breastfeeding policy that is routinely communicated to all health care staff.

2. Train all health care staff in skills necessary to implement this policy.

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

4.Help mothers initiate breastfeeding within a half hour of birth (one hour for cesarean birth).

5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants.

6. Give newborn infants no food or drink other than breastmilk unless medically indicated.

7. Practice rooming-in, allow mothers and infants to remain together 24 hours per day.

8. Encourage breastfeeding on demand.

9. Give no artificial teats or pacifiers to breastfeeding infants.

10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.


These steps seem simple and easy to implement, and the Canadian government signed an international agreement aiming to have many or all hospitals with maternity care across Canada designated Baby Friendly.  However, the vast majority of hospitals in Canada have failed to implement the Baby Friendly Hospital Initiative in the 20 years since this agreement was signed.  In fact, outside of Quebec, only five hospitals Canada are designated “Baby Friendly.”

St Joseph’s in Hamilton, Ontario

Toronto East General Hospital in Toronto

GR Baker Memorial Hospital in Quesnel, BC

BC Women’s Hospital in Vancouver, BC

Grand River Hospital in Kitchener, Ontario

(Breastfeeding Committee of Canada),

Within Quebec there is a long list of health centres, hospitals, birth centres, and public health units which are designated Baby Friendly, which can be viewed here (I don’t speak French well enough to adequately determine which listed facilities are hospitals and which are public health units, but the list includes at least four hospitals and three birth centres, as well as numerous other facilites).


Why aren’t more Canadian hospitals Baby Friendly?  Part of the problem with becoming accredited is that the ten requirements listed above are outlined in more detail and include specific stipulations such as in step 2, which is about training staff, and ‘training’ must be a high quality, WHO accredited breastfeeding course of 18 hours or more.  It also includes training of non medical staff such as cleaning staff and clerks.  So although the BFHI ten steps are simple, implementing them on maternity wards involves considerable cost, time, and dedication.  It is money well spent, and time and dedication which will result in improved maternal and infant health, but it is costly.  Many hospitals focus on improving their maternity wards in the direction of the ten steps, but fall short of accreditation because they fail to budget for training all staff to the standard expected by the BFHI.  Other areas besides staff training are stumbling blocks, as well.

The problem with striving towards the ten steps without accreditation is that when the ten steps are sort of followed, or almost fulfilled, women do not receive optimal support for breastfeeding.  Some maternity nurses will have accurate information and adequate training, or personal experience to draw from, and some will not.  Some cleaning staff will be supportive of breastfeeding and speak or act positively when exposed to it, and some will not.  Some women will be encouraged to initiate breastfeeding within the first half hour after birth, and some will not.  Some women whose babies go to the NICU will be aided in establishing and maintaining lactation despite separation, and some will not.  If an entire hospital has a vested interest in maintaining an accreditation as Baby Friendly, everyone will work harder to ensure that the environment of the hospital is supportive of breastfeeding. 

One of the most common complaints of women in the postpartum period regarding nursing support is that they get inconsistent breastfeeding information from nurses.  One nurse says your latch is good if your areola is entirely covered by the baby’s mouth, and another says areola coverage doesn’t matter.  One nurse says feed for 10 minutes per breast every feed, another says feed one side until the baby is full, then offer the other side.  One nurse says, “You have a great latch!” and another nurse says that because you have blisters on your nipples, your baby’s latch is poor.  If maternity ward staff are well trained with accurate information with high quality breastfeeding education courses approved by the WHO, this problem of inconsistent information will be drastically reduced.

Another stumbling block for some hospitals is the second part of the Baby Friendly requirements, which include compliance with the WHO International Code of Marketing of Breast-milk Substitutes.  For decades, hospitals around the world were given endless supplies of free infant formula for dissemination to new parents, and infant formula producers sponsored hospital activities and resources, which is a clear conflict of interest.  Canadian hospitals who wish to be designated Baby Friendly must purchase 100% of their infant formula, receive no funding from infant formula producers, and not provide free samples of formula to parents.

The Code seeks to protect breastfeeding by ensuring the ethical marketing of breastmilk substitutes by industry. The Code includes these ten important provisions:

  1. No advertising of products under the scope of the Code to the public.
  2. No free samples to mothers.
  3. No promotion of products in health care facilities, including the distribution of free or low-cost supplies.
  4. No company representatives to advise mothers.
  5. No gifts or personal samples to health workers.
  6. No words or pictures idealizing artificial feeding, including pictures of infants on products.
  7. Information to health workers should be scientific and factual.
  8. All information on artificial feeding, including the labels should explain the benefits of breastfeeding and all costs and hazards associated with artificial feeding.
  9. Unsuitable products such as sweetened condensed milk should not be promoted for babies.
  10. Products should be of a high quality and take account of the climatic and storage conditions of the country where they are used.

(BC Baby Friendly Network)

Here, again, Canadian hospitals strive to be closer to fulfilling these ten steps than they were in the past, but generally have difficulty with some steps, such as providing NO free samples to new parents.  Some parents need to supplement for a variety of reasons.  Families who are supplementing will frequently leave the hospital with a day or several days’ supply of infant formula, provided free of charge by the hospital.  In a Baby Friendly hospital, this can lead to suspension of accreditation and would be less likely to happen.  Free samples are powerful marketing tools for infant formula producers, as is the doctor-patient trust relationship.   Hospitals which participate in the dissemination of free formula are aiding infant formula marketers in undermining breastfeeding, according to the WHO Code.

Mothers of Change advocates for all hospitals in Canada to be designated Baby Friendly facilities.  China has over 6,000 Baby Friendly accredited hospitals, and Canada has a dismal handful or two.  Baby Friendly accreditation works.


Success Stories

Ten steps to successful breastfeeding
  • Have a written breastfeeding policy that is routinely communicated to all health care staff.
  • Train all health care staff in skills necessary to implement this policy.
  • Inform all pregnant women about the benefits and management of breastfeeding.
  • Help mothers initiate breastfeeding within one half-hour of birth.
  • Show mothers how to breastfeed and maintain lactation,even if they should be separated from their infants.
  • Give newborn infants no food or drink other than breastmilk, unless medically indicated.
  • Practice rooming in – that is, allow mothers and infants to remain together 24 hours a day.
  • Encourage breastfeeding on demand.
  • Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
  • Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

In Cuba, where 49 of the country’s 56 hospitals and maternity facilities are baby-friendly, the rate of exclusive breastfeeding at four mounths almost tripled in six years – from 25 per cent in 1990 to 72 per cent in 1996.

In the first two years of BFHI implementation at the Central Hospital of Libreville in Gabon, cases of neonatal diarrhoea fell by 15 per cent, diarrhoeal dehydration declined by 14 per cent and mortality fell by 8 per cent.

In China, which now has more than 6,000 Baby-Friendly Hospitals, exclusive breastfeeding in rural areas rose from 29 per cent in 1992 to 68 per cent in 1994; in urban areas, the increase was from 10 per cent to 48 per cent.

The Catholic University of Chile, Santiago, initiated one of the first baby-friendly hospitals. As a result, initiation of breastfeeding within the first two hours increased. With a strong Step 10, a monthly clinic, exclusive breastfeeding at 6 months increased from approximately 20% to over 60%.


(UNICEF in action)


How can you help?

Advocate for Baby Friendly accreditation at your local hospitals.  When you go for a maternity ward tour, ask if your hospital has Baby Friendly accreditation; if they don’t, ask why not?  Ask your midwife or physician which hospitals in your area are Baby Friendly and generate discussion about the benefits for Canadian families.  Join La Leche League, participate in the annual Quintessence Breastfeeding Challenge, or become a member of International Baby Food Action Network, or the Breastfeeding Committee of Canada.  Write letters to your local hospital administration, health minister, head of obstetrics, maternity ward, public health unit (health units can earn Baby Friendly accreditation as well), and health authority, advocating for a push to improve infant and maternal health via the Baby Friendly Hospital Initiative.  Change the world, improve health, support women!  One hospital at a time…

{ 2 comments… read them below or add one }

Amy Murray June 4, 2012 at 12:00 am

What a nice blog on the value of Baby-Friendly Hospital Initiative!


melissa v. June 4, 2012 at 3:19 pm

Thank you, Amy! We fully endorse the BFHI; hopefully raising awareness will help improve our quantity of BF Hospitals in Canada!


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