e-Library of Evidence for Nutrition Actions (eLENA)

Implementation of the Baby-friendly Hospital Initiative

Biological, behavioural and contextual rationale

Juana Willumsen
Consultant to WHO Department of Nutrition for Health and Development
July 2013

Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants1, providing protection from morbidity and mortality due to infectious diseases2 and chronic diseases later in life.3 Exclusive breastfeeding is recommended, starting within one hour of birth and for the first 6 months of life, with continued breastfeeding to 2 years of age and beyond.4 However, rates of initiation, exclusive breastfeeding and breastfeeding duration have fallen since the widespread introduction and promotion of breast-milk substitutes.5 Successful breastfeeding depends on a number of factors, including a re-normalisation of breastfeeding as the infant feeding method of choice through antenatal counselling and education and breastfeeding support to prevent and resolve breastfeeding difficulties.

The Baby-friendly Hospital Initiative (BFHI) was launched in 1991 by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF)6, in response to the 1990 Innocenti Declaration on the promotion, protection and support of breastfeeding7 and aims to provide health facilities with a framework for addressing practices which have a negative impact on breastfeeding. To achieve BFHI accreditation, health facilities must demonstrate a rate of at least 75% exclusive breastfeeding among mothers at discharge, adherence to the International Code of Marketing Breast-milk Substitutes and successful implementation of the Ten Steps to Successful Breastfeeding, as defined by the joint WHO/UNICEF statement, “Protecting, promoting and supporting breastfeeding: The special role of maternity services”, which state that every facility providing maternity services and care for newborn infants should:

  • 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 a half-hour of birth. (Interpreted as: Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour. Encourage mothers to recognize when their babies are ready to breastfeed and offer help if needed).
  • Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
  • Give newborn infants no food or drink other than breast milk unless medically indicated.
  • Practise rooming in - 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.8

Since BFHI began, more than 152 countries around the world have implemented the initiative.9 BFHI promotes a multi-level, multi-sector approach which, together with legislation regarding statutory maternity leave and protection of the breastfeeding rights of women in the workplace and enforcement of the Code of marketing of breast milk substitutes, is essential to effectively promote, protect and support breastfeeding.6 Monitoring and re-assessment of BFHI facilities are important as the initiative expands.

Although great progress has been made and BFHI has led to increased rates of exclusive breastfeeding reflected in improved health and survival10, there remain countries where BFHI efforts lag behind. The sustainability and scaling up of BFHI requires the integration of breastfeeding-related subjects into the curricula of health workers at all levels.11 Expanding BFHI beyond maternity services into neonatal, paediatric, and the community health services will help contribute to an improved continuity of care and breastfeeding outcomes.

BFHI has been shown to be very effective in increasing breastfeeding initiation, exclusive breastfeeding and breastfeeding duration in many countries, as well as improving mother’s health care experiences and reducing rates of infant abandonment.12 Given the short and long-term benefits of breastfeeding to the infant, mother and society, implementing BFHI – alongside with the other objectives stated in the Global Strategy for Infant and Young Child Feeding - continues to have an important role to play in health services worldwide.



The named authors alone are responsible for the views expressed in this document.

Declarations of interests

Conflict of interest statements were collected from all named authors and no conflicts were identified.