Baby-friendly Hospital Initiative

Health Care Issues: Baby-friendly (H)ospital Initiative

The Baby-friendly Hospital Initiative (BFHI) was launched by UNICEF and WHO in 1991. It is a world-wide endeavour to improve maternity care practices that were that are associated with successful establishment of early and exclusive breastfeeding. The practices were codified as the Ten Steps, developed in the 1980s, which include Protection (Steps 6 and 9) from distructive practices, Promotion (Steps 1 and 3) of optimal feeding, and Support (Steps 2, 4, 5, 8, 9 and 10) for practices and conditions that are associated with optimal infant feeding.

The process started in the 1980’s with the WHO/UNICEF Joint Statement: Protecting, promoting and supporting breastfeeding: The special role of maternity services, which drew attention to the critical role of health services for promoting breastfeeding, and in which the “Ten Steps to Successful Breastfeeding” were first published. In 1990, the Innocenti Declaration put forward as one of its main targets to “Ensure that all maternity facilities fully practise the Ten Steps to Successful Breastfeeding set out in the WHO/UNICEF statement on breastfeeding and maternity services.” The BFHI is called by various names around the world, including “Baby-friendly Initiative” or BFI in the UK, which provides a very helpful website, or the Mother-Baby-friendly Initiative in some countries.

Since 1991, the BFHI has spread all over the world, with more than 152 countries and over 20,000 hospitals having been accredited as “baby-friendly”, being awarded an official plaque, often with the well-known Picasso drawing of a breastfeeding mother, seen here. Tools and materials were developed for training of staff and assessment of practices to facilitate the implementation. Hospitals are accredited initially for a certain period of time, usually about 3-5 years, after which they must be reassessed and reaccredited, to ensure quality is maintained. Research on the impact of the initiative has shown it to be effective, and to increase breastfeeding rates. (See Tab below)

In 2009, revised tools and materials were produced by WHO and UNICEF to incorporate new evidence, and to expand the baby-friendly initiative to other healthcare settings and into the community in the context of the Global Strategy for Infant and Young Child Feeding. The updated materials reinforce implementation of the International Code of Marketing of Breast-milk Substitutes, introduce the concept of mother-friendly care, and care of pregnant women and mothers in the context of HIV and of emergencies. They include support for mothers who are not breastfeeding, and they provide more guidance for monitoring and reassessment.

Implementation may be initiated at national level, at regional level, or in individual hospitals, but either way includes the formation of a committee of relevant stakeholders to lead and guide the process. The persons responsible develop a plan of action, including a policy, and the training of all concerned staff, with outside help if necessary. A facility which aspires to become baby-friendly needs to conduct a self-assessment early in the process, to find out what practices need to change. Regular audits of practices are recommended to monitor developments.

The revised BFHI package includes:

Section 1: Background and Implementation, which provides guidance on the revised processes and expansion options at the country, health facility, and community level, recognizing that the Initiative has expanded and must be mainstreamed to some extent for sustainability, and includes:
1.1 Country Level Implementation
1.2 Hospital Level Implementation
1.3 The Global Criteria for BFHI
1.4 Compliance with the International Code of Marketing of Breast-milk Substitutes
1.5 Baby-friendly Expansion and Integration Options
1.6 Resources, references and websites

Section 2: Strengthening and sustaining the Baby-friendly Hospital Initiative: A course for decision-makers was adapted from the WHO course “Promoting breast-feeding in health facilities: A short course for administrators and policy-makers”. This can be used to orient hospital decisions makers (directors, administrators, key managers, etc.) and policy-makers to the Initiative and the positive impacts it can have and to gain their commitment to promoting and sustaining “Baby friendly”. There is a Course Guide and eight Session Plans with handouts and PowerPoint slides. Two alternative session plans and materials for use in settings with high HIV prevalence have been included.

Section 3: Breastfeeding Promotion and Support in a Baby-friendly Hospital, a 20-hour course for maternity staff, which can be used by facilities to strengthen the knowledge and skills of their staff towards successful implementation of the Ten Steps to Successful Breastfeeding. This section includes:
3.1 Guidelines for Course Facilitators including a Course Planning Checklist
3.2 Outlines of Course Sessions
3.3 PowerPoint slides for the Course

Section 4: Hospital Self-Appraisal and Monitoring, which provides tools that can be used by managers and staff initially, to help determine whether their facilities are ready to apply for external assessment, and, once their facilities are designated Baby-friendly, to monitor continued adherence to the Ten Steps. This section includes:
4.1 Hospital Self-Appraisal Tool
4.2 Guidelines and Tools for Monitoring

Section 5: External Assessment and Reassessment, which provides guidelines and tools for external assessors to use both initially, to assess whether hospitals meet the Global Criteria and thus fully comply with the Ten Steps, and then to reassess, on a regular basis, whether they continue to maintain the required standards. This section includes:
5.1 Guide for Assessors, including PowerPoint slides for assessor training
5.2 Hospital External Assessment Tool
5.3 Guidelines and Tool for External Reassessment
5.4 The BFHI Assessment Computer Tool



Every facility providing maternity services and care for newborn infants should:

  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. (Note: current research and any program support changing this to “within one hour”
  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. Practise rooming in – allow mothers and infants to remain together – 24 hours a day.
  8. Encourage breastfeeding on demand.
  9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
  10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Expanded BFHI

In the last 20 years, many lessons have been learned. In response, UNICEF/ WHO and partners developed a revised, updated and expanded BFHI package, released in 2009.

The UNICEF/WHO updated materials clarify the criteria for each of the Ten Steps and suggestions for implementation at the national and facility level and for attention to conflict to interest in programs. In addition, possible expansion of the initiative to intervene before and after the maternity period, and at a variety of societal levels – from family to community to nation – are described and offered for interpretation and implementation in a variety of settings. These include:

  • Pre and post maternity care:
    • Pre-delivery mother-baby friendly care,
    • Post-maternity clinic and physician office care and other facilities,
  • Special circumstances, such as care in the context of HIV and emergencies,
  • Beyond healthcare:
    • Community-level
    • Workplace
  • Suggestions for more.

Miriam Labbok presented a pilot Ten Steps for Community/Citywide Breastfeeding Friendly Family Initiative, which goes beyond the healthcare system, at the Breastfeeding and Feminism International Conference. BREASTFEEDING-FAMILY-FRIENDLY CITY


Much progress has been seen in the implementation of BFHI. A recent article includes data from BFHI monitoring and analysis of progress. In addition, multiple studies have shown the significant impact of implementation of the Ten Steps at the maternity facility level and of the BFHI at the national level. More recently, research has also examined the implementation and impact of selected steps. Selected article may be accessed, below.
Implementing the ten steps to successful breastfeeding in multiple hospitals serving low-wealth patients in the US- innovative research design

Barriers, Facilitators, and Recommendations Related to Implementing the Baby-Friendly Initiative (BFI) – An Integrative Review

Do Baby-Friendly Hospitals Influence Breastfeeding Duration on a National Level

Exploring the impact of the Baby-Friendly Hospital Initiative on trends in exclusive breastfeeding

The Impact of Hospital Practices on Women’s Likelihood of Fulfilling their Intention to Exclusively Breastfeed

Effect of Maternity-Care Practices on Breastfeeding

The Extent that Noncompliance with the Ten Steps to Successful Breastfeeding Influences Breastfeeding Duration

Implementing the Ten Steps for Successful Breastfeeding in Hospitals Serving Low-Wealth Patients