There is no doubt regarding the multiple benefits of breastfeeding for infants and society in general. Therefore, the World Health Organization (WHO) in a conjoint effort with United Nations International Children’s Emergency Fund (UNICEF) developed the “Ten Steps to Successful Breastfeeding” in 1992, which became the backbone of the Baby Friendly Hospital Initiative (BFHI). Following this development, many hospitals and countries intensified their position towards creating a “breastfeeding oriented” practice. Over the past two decades, the interest increased in the BFHI and the Ten Steps. However, alongside the implementation of the initiative, extensive research continues to evaluate the benefits and dangers of the suggested practices. Hence, it is our intention to make a critical evaluation of the current BFHI and the Ten Steps recommendations in consideration of the importance of providing an evidence-based breastfeeding supported environment for our mothers and infants.
Subscribe to Journal
Get full journal access for 1 year
only $20.67 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Rent or Buy article
Get time limited or full article access on ReadCube.
All prices are NET prices.
Section on B. Breastfeeding and the use of human milk. Pediatrics. 2012;129:e827–41.
Atchan M, Davis D, Foureur M. An historical document analysis of the introduction of the Baby Friendly Hospital Initiative into the Australian setting. Women Birth. 2017;30:51–62.
Wright A, Schanler R. The resurgence of breastfeeding at the end of the second millennium. J Nutr. 2001;131:421S–5.
WHO Guidelines Approved by the Guidelines Review Committee. Baby-Friendly Hospital initiative: revised, updated and expanded for integrated care. Geneva: World Health Organization and UNICEF; 2009.
USA. B-F. Guidelines and evaluation criteria for facilities seeking baby-friendly designation. 2016. https://d14abeop4cfxkt.cloudfront.net/cms/files/386/files/original/GEC2016.pdf. Accessed 30 Sept 2017.
Saadeh RJ. The Baby-Friendly Hospital Initiative 20 years on: facts, progress, and the way forward. J Hum Lact. 2012;28:272–275.
Feldman-Winter L, Ustianov J, Anastasio J, Butts-Dion S, Heinrich P, Merewood A, et al. Best fed Beginnings: a nationwide quality improvement initiative to increase breastfeeding. Pediatrics. 2017;140:3121.
Labbok MH. Global baby-friendly hospital initiative monitoring data: update and discussion. Breastfeed Med. 2012;7:210–22.
Meek JY, Noble L. Implementation of the Ten steps to successful breastfeeding saves lives. JAMA Pediatr. 2016;170:925–6.
Bass JL, Gartley T, Kleinman R. Unintended consequences of current breastfeeding initiatives. JAMA Pediatr. 2016;170:923–924.
Goldsmith JP. Hospitals should balance skin-to-skin contact with safe sleep policies. AAP News. 2013;34.
Flaherman V, Von Kohorn I. Interventions intended to support breastfeeding: updated assessment of benefits and harms. JAMA. 2016;316:1685–1687.
Vallenas C, Savage F. Evidence for the ten steps to successful breastfeeding. 1998. http://apps.who.int/iris/bitstream/10665/43633/1/9241591544_eng.pdf. Accessed 30 Sept 2017.
Semenic S, Childerhose JE, Lauziere J, Groleau D. Barriers, facilitators, and recommendations related to implementing the Baby-Friendly Initiative (BFI): an integrative review. J Hum Lact. 2012;28:317–34.
Lubold AM. The effect of family policies and public health initiatives on breastfeeding initiation among 18 high-income countries: a qualitative comparative analysis research design. Int Breastfeed J. 2017;12:34.
Feldman-Winter L. Evidence-based interventions to support breastfeeding. Pediatr Clin North Am. 2013;60:169–87.
U.S. Department of Health and Human Services. The surgeon general’s call to action to support breastfeeding. In: Office of the Surgeon Genera, editor. Rockville, MD, 2011.
Patnode CD, Henninger ML, Senger CA, Perdue LA, Whitlock EP. Primary care interventions to support breastfeeding: updated evidence report and systematic review for the us preventive services task force. JAMA. 2016;316:1694–705.
Kramer MS, Chalmers B, Hodnett ED, Sevkovskaya Z, Dzikovich I, Shapiro S, et al. Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus. JAMA. 2001;285:413–20.
Atchan M, Davis D, Foureur M. The impact of the Baby Friendly Health Initiative in the Australian health care system: a critical narrative review of the evidence. Breastfeed Rev. 2013;21:15–22.
Merten S, Dratva J, Ackermann-Liebrich U. Do baby-friendly hospitals influence breastfeeding duration on a national level? Pediatrics. 2005;116:e702–8.
Schmied V, Gribble K, Sheehan A, Taylor C, Dykes FC. Ten steps or climbing a mountain: a study of Australian health professionals’ perceptions of implementing the baby friendly health initiative to protect, promote and support breastfeeding. BMC Health Serv Res. 2011;11:208.
Walsh AD, Pincombe J, Henderson A. An examination of maternity staff attitudes towards implementing Baby Friendly Health Initiative (BFHI) accreditation in Australia. Matern Child Health J. 2011;15:597–609.
Heymann J, Raub A, Earle A. Breastfeeding policy: a globally comparative analysis. Bull World Health Organ. 2013;91:398–406.
Gatti L. Maternal perceptions of insufficient milk supply in breastfeeding. J Nurs Scholarsh. 2008;40:355–63.
Robert E, Coppieters Y, Swennen B, Dramaix M. The reasons for early weaning, perceived insufficient breast milk, and maternal dissatisfaction: comparative studies in two belgian regions. Int Sch Res Not. 2014;2014:678564.
Anstey EH, Chen J, Elam-Evans LD, Perrine CG. Racial and geographic differences in breastfeeding - united states, 2011-2015. MMWR Morb Mortal Wkly Rep. 2017;66:723–7.
Hawke BA, Dennison BA, Hisgen S. Improving hospital breastfeeding policies in New York State: development of the model hospital breastfeeding policy. Breastfeed Med. 2013;8:3–7.
Schanler RJ, O’Connor KG, Lawrence RA. Pediatricians’ practices and attitudes regarding breastfeeding promotion. Pediatrics. 1999;103:E35.
Feldman-Winter LB, Schanler RJ, O’Connor KG, Lawrence RA. Pediatricians and the promotion and support of breastfeeding. Arch Pediatr & Adolesc Med. 2008;162:1142–9.
Feldman-Winter L, Szucs K, Milano A, Gottschlich E, Sisk B, Schanler RJ. National trends in pediatricians’ practices and attitudes about breastfeeding: 1995 to 2014. Pediatrics. 2017;140:1229.
Meek JY. Pediatrician competency in breastfeeding support has room for improvement. Pediatrics. 2017;140:2509.
Fairbank L, O’Meara S, Renfrew MJ, Woolridge M, Sowden AJ, Lister-Sharp D. A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding. Health Technol Assess. 2000;4:1–171.
Meedya S, Fernandez R, Fahy K. Effect of educational and support interventions on long-term breastfeeding rates in primiparous women: a systematic review and meta-analysis. JBI Database Syst Rev Implement Rep. 2017;15:2307–2332.
Wouk K, Tully KP, Labbok MH. Systematic review of evidence for baby-friendly hospital initiative step 3. J Hum Lact. 2017;33:50–82.
Lumbiganon P, Martis R, Laopaiboon M, Festin MR, Ho JJ, Hakimi M. Antenatal breastfeeding education for increasing breastfeeding duration. Cochrane Database Syst Rev. 2016;12:CD006425.
Munn AC, Newman SD, Mueller M, Phillips SM, Taylor SN. The impact in the united states of the baby-friendly hospital initiative on early infant health and breastfeeding outcomes. Breastfeed Med. 2016;11:222–30.
Chung M, Raman G, Trikalinos T, Lau J, Ip S. Interventions in primary care to promote breastfeeding: an evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149:565–82.
de Jager E, Broadbent J, Fuller-Tyszkiewicz M, Nagle C, McPhie S, Skouteris H. A longitudinal study of the effect of psychosocial factors on exclusive breastfeeding duration. Midwifery. 2015;31:103–11.
McFadden A, Gavine A, Renfrew MJ, Wade A, Buchanan P, Taylor JL, et al. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Syst Rev. 2017;2:CD001141.
Hinsliff-Smith K, Spencer R, Walsh D. Realities, difficulties, and outcomes for mothers choosing to breastfeed: primigravid mothers experiences in the early postpartum period (6–8 weeks). Midwifery. 2014;30:e14–9.
Tully KP, Ball HL. Maternal accounts of their breast-feeding intent and early challenges after caesarean childbirth. Midwifery. 2014;30:712–9.
Roll CL, Cheater F. Expectant parents’ views of factors influencing infant feeding decisions in the antenatal period: a systematic review. Int J Nurs Stud. 2016;60:145–55.
Labarere J, Gelbert-Baudino N, Ayral AS, Duc C, Berchotteau M, Bouchon N, et al. Efficacy of breastfeeding support provided by trained clinicians during an early, routine, preventive visit: a prospective, randomized, open trial of 226 mother-infant pairs. Pediatrics. 2005;115:e139–46.
Ryan AS, Zhou W. Lower breastfeeding rates persist among the special supplemental nutrition program for women, infants, and children participants, 1978-2003. Pediatrics. 2006;117:1136–46.
Francescon J, Haile ZT, Kling D, Chertok I. Association between wic enrollment and exclusive breastfeeding at 3 months postpartum among low-income mothers. J Am Osteopath Assoc. 2016;116:770–9.
Hedberg IC. Barriers to breastfeeding in the WIC population. MCN Am J Matern Child Nurs. 2013;38:244–9.
Jacobson LT, Twumasi-Ankrah P, Redmond ML, Ablah E, Hines RB, Johnston J, et al. Characteristics associated with breastfeeding behaviors among urban versus rural women enrolled in the Kansas WIC program. Matern Child Health J. 2015;19:828–39.
Ahluwalia IB, Tessaro I, Grummer-Strawn LM, MacGowan C, Benton-Davis S. Georgia’s breastfeeding promotion program for low-income women. Pediatrics. 2000;105:E85.
Schultz DJ, Byker Shanks C, Houghtaling B. The impact of the 2009 special supplemental nutrition program for women, infants, and children food package revisions on participants: a systematic review. J Acad Nutr Diet. 2015;115:1832–46.
Balogun OO, O’Sullivan EJ, McFadden A, Ota E, Gavine A, Garner CD, et al. Interventions for promoting the initiation of breastfeeding. Cochrane Database Syst Rev. 2016;11:CD001688.
Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2016;11:CD003519.
Feldman-Winter L, Goldsmith JP, Committee On F, Newborn, Task Force On Sudden Infant Death Syndrome. Safe sleep and skin-to-skin care in the neonatal period for healthy term newborns. Pediatrics. 2016;138:e20161889.
Crenshaw J. Care practice #6: no separation of mother and baby, with unlimited opportunities for breastfeeding. J Perinat Educ. 2007;16:39–43.
Davanzo R, De Cunto A, Paviotti G, Travan L, Inglese S, Brovedani P, et al. Making the first days of life safer: preventing sudden unexpected postnatal collapse while promoting breastfeeding. J Hum Lact. 2015;31:47–52.
Jaafar SH, Ho JJ, Lee KS. Rooming-in for new mother and infant versus separate care for increasing the duration of breastfeeding. Cochrane Database Syst Rev. 2016;CD006641.
Rodriguez-Alarcon J, Melchor JC, Linares A, Aranguren G, Quintanilla M, Fernandez-Llebrez L, et al. Early neonatal sudden death or near death syndrome. Epidemiol Study 29 cases Acta Paediatr. 1994;83:704–8.
Espagne S, Hamon I, Thiebaugeorges O, Hascoet JM. [Sudden death of neonates in the delivery room]. Arch Pediatr. 2004;11:436–9.
Branger B, Savagner C, Roze JC, Winer N. Pediatres des Maternites des P-d-l-L. [Eleven cases of early neonatal sudden death ou near death of full term and healthy neonates in maternity wards]. J Gynecol Obstet Biol Reprod. 2007;36:671–9.
Dageville C, Pignol J, De Smet S. Very early neonatal apparent life-threatening events and sudden unexpected deaths: incidence and risk factors. Acta Paediatr. 2008;97:866–9.
Ottaviani G. Sudden infant and perinatal unexplained death: are we moving forward yet? Cardiovasc Pathol. 2011;20:302–6.
Poets A, Steinfeldt R, Poets CF. Sudden deaths and severe apparent life-threatening events in term infants within 24 h of birth. Pediatrics. 2011;127:e869–73.
Becher JC, Bhushan SS, Lyon AJ. Unexpected collapse in apparently healthy newborns--a prospective national study of a missing cohort of neonatal deaths and near-death events. Arch Dis Child Fetal Neonatal Ed. 2012;97:F30–4.
Poets A, Urschitz MS, Steinfeldt R, Poets CF. Risk factors for early sudden deaths and severe apparent life-threatening events. Arch Dis Child Fetal Neonatal Ed. 2012;97:F395–7.
Feldman K. The unexpected: sudden infant death in the postnatal period. Paediatr Child Health. 2013;18:360.
Lutz TL, Elliott EJ, Jeffery HE. Sudden unexplained early neonatal death or collapse: a national surveillance study. Pediatr Res. 2016;80:493–8.
Andres V, Garcia P, Rimet Y, Nicaise C, Simeoni U. Apparent life-threatening events in presumably healthy newborns during early skin-to-skin contact. Pediatrics. 2011;127:e1073–6.
Ferrarello D, Carmichael T. Sudden unexpected postnatal collapse of the newborn. Nurs Women’s Health. 2016;20:268–75.
Hays S, Feit P, Barre P, Cottin X, Huin N, Fichtner C, et al. [Respiratory arrest in the delivery room while lying in the prone position on the mothers’ chest in 11 full term healthy neonates]. Arch Pediatr. 2006;13:1067–8.
Task Force On Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment. Pediatrics. 2016;138:e20162938.
Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2012;CD003517.
Flaherman VJ, Aby J, Burgos AE, Lee KA, Cabana MD, Newman TB. Effect of early limited formula on duration and exclusivity of breastfeeding in at-risk infants: an RCT. Pediatrics. 2013;131:1059–65.
Stranak Z, Feyereislova S, Cerna M, Kollarova J, Feyereisl J. Limited Amount of formula may facilitate breastfeeding: randomized, controlled trial to compare standard clinical practice versus limited supplemental Feeding. PLoS ONE. 2016;11:e0150053.
Schubiger G, Schwarz U, Tönz O. UNICEF/WHO baby-friendly hospital initiative: does the use of bottles and pacifiers in the neonatal nursery prevent successful breastfeeding? Eur J Pediatr. 2012;156:874–7.
Howard CR, Howard FM, Lanphear B, Eberly S, deBlieck EA, Oakes D, et al. Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics. 2003;111:511–8.
Smith HA, Becker GE. Early additional food and fluids for healthy breastfed full-term infants. Cochrane Database Syst Rev. 2016;CD006462.
Nelson EA, Yu LM, Williams S, International Child Care Practices Study Group M. International Child Care Practices study: breastfeeding and pacifier use. J Hum Lact. 2005;21:289–95.
Hauck FR, Omojokun OO, Siadaty MS. Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis. Pediatrics. 2005;116:e716–23.
Lubbe W, Ten Ham-Baloyi W. When is the use of pacifiers justifiable in the baby-friendly hospital initiative context? A clinician’s guide. BMC Pregnancy Childbirth. 2017;17:130.
Jenik AG, Vain NE, Gorestein AN, Jacobi NE. Pacifier, Breastfeeding Trial G. Does the recommendation to use a pacifier influence the prevalence of breastfeeding? J Pediatr. 2009;155:350–354. e351
Pincombe J, Baghurst P, Antoniou G, Peat B, Henderson A, Reddin E. Baby Friendly Hospital Initiative practices and breast feeding duration in a cohort of first-time mothers in Adelaide, Australia. Midwifery. 2008;24:55–61.
Karabulut E, Yalcin SS, Ozdemir-Geyik P, Karaagaoglu E. Effect of pacifier use on exclusive and any breastfeeding: a meta-analysis. Turk J Pediatr. 2009;51:35–43.
O’Connor NR, Tanabe KO, Siadaty MS, Hauck FR. Pacifiers and breastfeeding: a systematic review. Arch Pediatr & Adolesc Med. 2009;163:378–82.
Jaafar SH, Ho JJ, Jahanfar S, Angolkar M. Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding. Cochrane Database Syst Rev. 2016:CD007202.
Bartick MC, Nickel NC, Hanley LE. Evidence for the baby-friendly hospital initiative to support breastfeeding. JAMA. 2017;317:770–1.
Martens PJ. What do Kramer’s Baby-Friendly Hospital Initiative PROBIT studies tell us? A review of a decade of research. J Hum Lact. 2012;28:335–42.
Merewood A, Mehta SD, Chamberlain LB, Philipp BL, Bauchner H. Breastfeeding rates in US Baby-Friendly hospitals: results of a national survey. Pediatrics. 2005;116:628–34.
Philipp BL, Merewood A, Miller LW, Chawla N, Murphy-Smith MM, Gomes JS, et al. Baby-Friendly Hospital initiative improves breastfeeding initiation rates in a US hospital setting. Pediatrics. 2001;108:677–81.
Yotebieng M, Labbok M, Soeters HM, Chalachala JL, Lapika B, Vitta BS, et al. Ten steps to successful breastfeeding programme to promote early initiation and exclusive breastfeeding in DR Congo: a cluster-randomised controlled trial. Lancet Glob Health. 2015;3:e546–55.
DelliFraine J, Langabeer J 2nd, Williams JF, Gong AK, Delgado RI, Gill SL. Cost comparison of baby friendly and non-baby friendly hospitals in the United States. Pediatrics. 2011;127:e989–94.
Brodribb W, Kruske S, Miller YD. Baby-friendly hospital accreditation, in-hospital care practices, and breastfeeding. Pediatrics. 2013;131:685–92.
Hawkins SS, Stern AD, Baum CF, Gillman MW. Evaluating the impact of the Baby-Friendly Hospital Initiative on breast-feeding rates: a multi-state analysis. Public Health Nutr. 2015;18:189–97.
Hawkins SS, Stern AD, Baum CF, Gillman MW. Compliance with the Baby-Friendly Hospital Initiative and impact on breastfeeding rates. Arch Dis Child Fetal Neonatal Ed. 2014;99:F138–43.
Howe-Heyman A, Lutenbacher M. The Baby-Friendly Hospital Initiative as an Intervention to Improve Breastfeeding Rates: A Review of the Literature. J Midwifery Women’s Health. 2016;61:77–102.
Ibanez G, de Reynal de Saint Michel C, Denantes M, Saurel-Cubizolles MJ, Ringa V, Magnier AM. Systematic review and meta-analysis of randomized controlled trials evaluating primary care-based interventions to promote breastfeeding in low-income women. Fam Pract. 2012;29:245–54.
We sincerely thank the comments and critical review of the manuscript done by Dr. Henrietta Bada.
Conflict of Interest
The authors declare that they have no conflict of interest.
About this article
Cite this article
Gomez-Pomar, E., Blubaugh, R. The Baby Friendly Hospital Initiative and the ten steps for successful breastfeeding. a critical review of the literature. J Perinatol 38, 623–632 (2018). https://doi.org/10.1038/s41372-018-0068-0
Neonatal intensive care unit admissions before and after the adoption of the baby friendly hospital initiative
The Journal of Maternal-Fetal & Neonatal Medicine (2020)
Improved breastfeeding duration with Baby Friendly Hospital Initiative implementation in a diverse and underserved population
Recommendations for treating life-threatening Kaposi sarcoma during pregnancy in HIV-positive women in low income countries
International Journal of STD & AIDS (2020)
Clinical Lactation (2019)
Re: “A Critical Review of the Baby-Friendly Hospital Initiative Is in the Works” by Eidelman (Breastfeed Med 2018;13(9):557–558)
Breastfeeding Medicine (2019)