Baby-Friendly Hospital Initiative (BFHI)

Baby Friendly USA, Inc.


The Baby-Friendly Hospital Initiative (BFHI) is a hospital accreditation program and PSE change intervention that was created by the United Nations Children’s Fund and the World Health Organization to recognize hospitals and birth centers around the world that offer an optimal level of care for infant feeding and mother/baby bonding. It requires facilities with the Baby-Friendly designation to provide direct breastfeeding education and support to families.  In the United States, Baby-Friendly USA, Inc. is the nonprofit national authority for the Baby-Friendly Hospital Initiative and conducts all activities necessary to assess, accredit birthing facilities with the Baby-Friendly designation.. In order to receive the Baby-Friendly designation, maternity facilities must meet the BFHI criteria for implementing the Ten Steps to Successful Breastfeeding, which consists of evidence-based practices that have been shown to increase breastfeeding initiation and duration. To attain designation facilities must also follow the International Code of Marketing of Breast-milk Substitutes which outlines restrictions for marketing of breast-milk substitutes, infant feeding bottles and artificial nipples. Infant formula and related products must be purchased at fair market rates and the facility may not accept any free or discounted breast-milk substitute distributed and/or sponsored by formula companies.

Target Behavior: Breastfeeding

Intervention Type: Direct Education, PSE Change

Intervention Reach and Adoption

The BFHI assists hospitals in giving all mothers the information, confidence, and skills necessary to successfully initiate and continue breastfeeding their babies. Results of the BFHI demonstrated that successful implementation of Baby-Friendly policies is associated with an increase in breastfeeding rates across all ethnic and socioeconomic groups. As of October 7, 2016, there were 378 Baby-Friendly hospitals in the United States.

Setting: Health care

Target Audience: Pregnant/Breastfeeding Women

Race/Ethnicity: All

Intervention Components

BFHI includes the following main components:

  1. Multi-disciplinary Task Force Formation: The Task Force provides leadership to guide the facility through changes throughout the organization and assists with fostering knowledge and support of the initiative throughout the facility. The task force is responsible for all aspects of planning, implementation, and evaluation required to comply with the Baby-Friendly Hospital Initiative’s (BFHI) Ten Steps to Successful Breastfeeding.
  2. Self-Assessment: Facilities are required to complete a Self-Appraisal Survey and Facility Data Sheet in the Discovery Phase to help assess where the facility is in terms of breastfeeding policies and procedures, exclusivity rates, etc. These items are completed when the facility first enters the 4D pathway. The facility continues to monitor practices and collect data while working towards and following Designation. This is done by following a Data Collection Plan that the facility creates in the Development Phase and by utilizing audit tools to insure they are in compliance with the Baby-Friendly Guidelines and Evaluation Criteria.
  3. Comprehensive Infant feeding Policy: The facility develops a breastfeeding policy that addresses the implementation of the Ten Steps to Successful Breastfeeding and the International Code of Marketing of Breast-Milk Substitutes. The policy is communicated to all healthcare staff and the staff receives the training and education necessary to implement this policy.
  4. Staff Education: Guidelines from Baby-Friendly USA require that any pediatrician, obstetrician, family practice physician or advanced practice registered nurse that has staff privileges at a Baby-Friendly hospital or birth center receive education on the required topics as indicated in the Guidelines and Evaluation Criteria. The amount and content of the training offered is tailored to the needs of the professionals.
  5. Education and Support for Mothers: Lactation consultants teach weekly breastfeeding classes, and peer counselors are hired to work with mothers before and after discharge.  Peer counselors teach mothers of healthy newborns and neonatal intensive care patients about the benefits of breastfeeding and the importance of skin-to-skin contact between caregiver and infant.
  6. Paying for Formula: As part of the requirements to achieve Baby-Friendly designation a hospital must follow the International Code of Marketing of Breast-Milk Substitutes. One of the major tenants of “The Code” stipulates the facility cannot accept free formula from formula manufacturers.  This includes the formula-company sponsored gift bags that are distributed on postpartum floors in most hospitals.  Many United States hospitals find compliance with this step to be the greatest barrier to obtaining Baby-Friendly designation.  Paying for formula need not become the rate-limiting step in the process of becoming Baby-Friendly.

Intervention Materials

Intervention Costs

Cost information coming soon.

Evidence Summary

BFHI was reviewed as a research-tested intervention in the context of its implementation at Boston Medical Center (BMC).  Three peer reviewed articles examined the effect of Baby-Friendly practices on: breastfeeding initiation and exclusivity rates (Philipp et al, 2001); sustained breastfeeding initiation rates (Philipp et al, 2003); and breastfeeding duration rates at six months of age (Merewood et al, 2007).

Intervention Effect (initiation and exclusivity rates): Breastfeeding initiation rates were compared at BMC before (1995), during (1998), and after (1999) the Baby-Friendly policies were implemented.  Breastfeeding initiation was defined as an infant receiving any amount of breast milk while in the hospital after birth.  Random medical chart review of 200 records showed that the breastfeeding initiation rates increased from 58% (1995) to 77.5% (1998) to 86.5% (1999).  Infants exclusively breastfed, defined as receiving no formula while in the hospital, increased among US born, black mothers in this population from 34% (1995) to 64% (1998) to 74% (1999).

Intervention Effect (sustained initiation rates): Breastfeeding initiation rates were again measured in 2000 and 2001 and compared with initiation rates in 1999 (the year that BMC received Baby-Friendly designation) to determine if the increased rates could be sustained over time.  Breastfeeding initiation rates remained high: 87% (1999), 82% (2000), and 87% (2001).

Intervention Effect (duration rates):  A random selection of 350 medical records of infants born in 2003 at BMC were reviewed, and of the eligible infants who returned for the six-month follow-up visit, 37.1% were still breastfeeding at six months of age.  Among a predominantly low-income, black population, breastfeeding rates at 6 months were comparable to the overall US population.

Classification: Research-tested


Evaluation Indicators

Based on the SNAP-Ed Evaluation Framework, the following outcome indicators can be used to evaluate intervention progress and success.

Readiness and Capacity – Short Term (ST) Changes – Medium Term (MT) Effectiveness and Maintenance – Long Term (LT) Population Results (R)
Individual R8
Environmental Settings ST6 MT5 LT7
Sectors of Influence MT11, MT12 LT19

Evaluation Materials

Baby-Friendly USA released updated “Guidelines and Evaluation Criteria for Facilities Seeking Baby-Friendly Designation” (2016 Revision).  As indicated by the title, it includes both the Guidelines facilities would need to follow to achieve full Baby-Friendly status and Evaluation Criteria that clearly spell out the minimum standards that a facility must achieve in order to become Baby-Friendly designated.

Further, facilities enrolled in the 4-D Pathway receive tool kits which consist of an assortment of planning and audit tools.


Additional Information

Website: The Baby Friendly USA website ( includes an overview of Baby-Friendly Hospital Initiative, a list of U. S. Baby-Friendly Designated Hospitals and Birth Centers, the process for achieving Baby-Friendly designation, the 4-D Pathway to Baby-Friendly designation, and introductory tools and information for those interested in entering the 4-D Pathway.

Contact name:
Baby-Friendly USA, Inc.
125 Wolf Rd., Suite 402
Albany, NY 12205
Phone:  (518) 621-7982
Fax:  (518) 621-7983