Do Breastfeeding Policies and Practices in Neonatal Intensive Care Units Differ by Baby-Friendly Hospital Initiative Status?

Abstract

Background:

The Baby-Friendly Hospital Initiative (BFHI) was launched in 1991 by the World Health Organization and United Nations International Children’s Emergency Fund to promote and support breastfeeding within hospitals. Prior studies have assessed the associations between BFHI and breastfeeding, but there is limited evidence examining the policies and practices in neonatal intensive care units (NICUs) that, in turn, may influence breastfeeding.

Objective:

The goal of this analysis was to assess whether BFHI status was associated with breastfeeding policies and practices in NICUs in a sample of U.S.-based hospitals.

Methods:

A cross-sectional survey was sent to hospital administrators at 1,285 facilities (817 BFHI and 468 non-BFHI) throughout all regions of the United States and assessed whether hospitals were implementing breastfeeding support policies and practices in NICUs. Pearson’s chi-squared and Fisher’s exact tests were performed to assess associations between BFHI status and reported 6 breastfeeding policies and 11 breastfeeding practices.

Results:

Among all 259 respondents (BFHI: 68/102 [67%], non-BFHI: 73/157 [47%]), Baby-Friendly^® status was significantly associated with having specific breastfeeding practices in the NICU (67% versus 47%, p = 0.001). More BFHI compared with non-BFHI hospitals reported assessing milk supply of mothers (90% versus 75%, p = 0.026) and communicating the medical benefits of breastfeeding (91% versus 75%, p = 0.012) to new parents. There were, however, no differences by BFHI status in the other breastfeeding policies and practices.

Introduction

Breastfeeding sets a strong foundation for health during the critical window of the first 1,000 days of life and beyond.¹ To maximize this benefit, the Baby-Friendly Hospital Initiative (BFHI) was launched in 1991 by the World Health Organization and United Nations International Children’s Emergency Fund as an intervention to implement the Ten Steps to successful breastfeeding and the international code of marketing breast milk substitutes.² The overall goal was to assist hospitals in providing parents with the necessary skills and confidence to initiate and sustain breastfeeding and to create environments supportive of breastfeeding. In 2011, the Surgeon General called for accelerated implementation of BFHI across the United States, resulting in an increase in births occurring in BFHI facilities from 3% in 2007 to 27% in 2022.³

Infant admissions to the neonatal intensive care unit (NICU) pose substantial challenges to breastfeeding in a vulnerable population that has much to gain from the consumption of human milk. In addition to the critical window of growth and neurodevelopment, NICU infants can also benefit from human milk consumption for reasons ranging from the prevention of hospital-acquired infections to requiring less pharmacological treatment for neonatal abstinence syndrome.^4,5 Importantly, the consumption of human milk can help with necrotizing enterocolitis (NEC), late-onset sepsis, chronic lung disease, and retinopathy of prematurity.⁶ The consumption of breast milk by preterm infants during this critical window has been shown to improve neurodevelopmental outcomes.⁷ Breast milk has the capacity to change in synchronicity with the infant’s nutritional needs, such as having increased protein in milk from mothers who deliver preterm, serving as a developmental and protective factor for neonates.⁸ These reasons indicate the need for policies and practices that will support breastfeeding for infants in the NICU. These policies can include those governing human milk handling and exclusively using human milk where appropriate.^9,10 Practices to support breastfeeding include providing education and technical support for new parents.

Breastfeeding in the NICU may be more challenging due to mother–infant separation and medical contraindication. This may lead to greater disparities in breastfeeding rates between NICU and non-NICU infants. Although an abundance of studies examined the association of BFHI and breastfeeding rates with health outcomes,^11–14 there is limited evidence on policies and practices in NICUs that may influence human milk consumption.¹⁵ Therefore, the purpose of this analysis was to assess whether BFHI status was associated with breastfeeding policies and practices in NICUs in a sample of U.S.-based hospitals.

Methods

Overview

This analysis was part of an exploratory study on breastfeeding practices in hospitals and birthing facilities participating in the BFHI with the aim of assessing practices and policies that support breastfeeding women of color and low income. Between fall 2019 and early spring 2020, a cross-sectional survey of hospital breastfeeding practices and policies was administered to hospital administrators throughout all regions of the United States in hospitals with and without BFHI status.¹⁶ The survey tool REDCap was used. Respondents provided online informed consent prior to survey completion. The aim of the larger study was to assess the overall landscape of breastfeeding support. The survey assessed breastfeeding support policies and practices within birthing facilities. The authors asked about overall policies and practices to support women of color and women with low socioeconomic status in all hospital facilities. The larger study provides a more detailed description of the methods.¹⁶ This study was determined to be exempt by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board—IRB No: 00009842.

Design and sampling

A total of 1,285 U.S. hospitals were identified from the American Hospital Association (AHA) database. Lists of BFHI and non-BFHI hospitals were received separately, categorized by hospital size for each list, and the same number of hospitals were selected from each list. To account for the smaller pool of BFHI hospitals, oversampling among BFHI hospitals was done to have equal numbers of BFHI and non-BFHI. Information on the number of beds was identified through a combination of AHA data and online searches where the AHA dataset did not include hospitals’ bed size information. Hospitals were categorized as small if they had 1–99 beds, medium if they had 100–299 beds, and large if they had 300 or more beds.

Data collection

A letter of invitation and electronic survey were emailed to U.S. hospital administrators in 2019 at 409 BFHI hospitals and 879 non-BFHI hospitals. If emails to hospital administrators bounced back, hospitals were contacted via phone. Follow-up reminder emails were sent weekly for 3 weeks. We ceased data collection earlier than planned due to the onset of the COVID-19 pandemic. The survey assessed the presence of breastfeeding support policies and practices, contained 14 questions in total, and took ∼20 minutes to complete. One survey question asked respondents if their facility engaged in specific breastfeeding practices in the NICU. If respondents selected yes, subsequent questions asked about policies and practices specific to the NICU. Participants were asked to select from a list of literature and clinical practice guideline-derived policies and practices, which ones their hospital engaged in. Respondents were incentivized to complete the survey with a $20 gift card. Facilities were coded as having established or emerging BFHI designation using data from Baby-Friendly^® USA, Inc., the accrediting body for the BFHI in the United States. Respondents were asked to identify breastfeeding practices that their facility engaged in from the perspective of their facility. If respondents selected that their facility engages in breastfeeding practices, they were asked to select what challenges, if any, that their facility faced related to the support practices.

Data analysis

Frequencies and percentages were calculated for respondents who answered the NICU questions (Table 1). If hospitals had an established BFHI designation or had an “emerging” designation (were on the 4D pathway to becoming BFHI), they were categorized as “established.” If there was either no current designation or a previous designation that was not renewed, hospitals were considered not having Baby-Friendly status. Pearson’s chi-squared and Fisher’s exact tests were performed to assess associations between Baby-Friendly status and reported (1) whether or not breastfeeding policies and practices exist in the NICU, and as a follow-up, (2) the specific breastfeeding policies within the NICU, and (3) the specific breastfeeding practices within the NICU. A sensitivity analysis was performed to determine whether including “emerging” status with “established” Baby-Friendly led to different results (Table 3). Statistical analysis was conducted using IBM SPSS Statistics Version 29.0.0.0 (241) for Mac (Armonk, NY: IBM Corp), with an alpha <0.05 significance level.

Table 1.

Demographic and Facility Characteristics of Hospital Administrators (N = 259)

	Non-BFHI (N = 157)N (%)	BFHI (N = 102)N (%)
Variable^a
Profession type (n = 250)
Clinical profession	79 (53)	46 (46)
Nursing staff	69 (46)	31 (31)
Lactation consultant	29 (19)	26 (26)
Facility part of larger health system (n = 258)	93 (59)	73 (72)
Region (n = 258)
West	28 (18)	14 (14)
South	49 (31)	41 (41)
Midwest	55 (35)	24 (24)
Northeast	25 (16)	22 (22)
Facility type (n = 258)
Labor and delivery unit in a hospital	153 (97)	95 (94)
Birthing center affiliated with a hospital	2 (1)	4 (4)
Birthing center not affiliated with a hospital	1 (1)	1 (1)
Other/unsure	1 (1)	1 (1)
Facility size (n = 240)
Small (bed# 1–99)	62 (42)	29 (31)
Medium (bed# 100–499)	62 (42)	48 (51)
Large (bed# ≥500)	22 (15)	17 (18)

n represents number of participants with available or nonmissing data.

BFHI, Baby-Friendly Hospital Initiative.

Results

A total of 316 hospitals completed the survey. Among these, 26 hospitals were removed because they did not provide consent and we did not attempt to follow up with these hospitals. The final sample size was 290 (113 BFHI and 177 non-BFHI hospitals). Among those, 259 responded to the NICU portion of the survey (102 BFHI and 157 non-BFHI hospitals). Approximately 50% worked primarily in a clinical setting (versus office setting), among which 40% were nurse managers and 22% worked in the area of lactation. Over half of all facilities (64%) were part of a larger health system (Table 2). Approximately one-third were in the South (35%), one-third were in the Midwest (31%), 18% were in the Northeast, and 16% were in the West. Nearly all facilities were labor and delivery units within a hospital (96%), and the remaining 4% were birthing centers. Fewer than half of all responding facilities were classified as medium sized (46%), 38% were classified as small, and 16% were classified as large. Among respondents, 27% (n = 69) were from facilities with a current BFHI designation, 13% (n = 33) were from facilities with an emerging BFHI designation, 59% (n = 154) were from facilities with no designation, and 1% (n = 3) had prior BFHI designation with no renewal.

Table 2.

Breastfeeding Policies and Practices in NICUs by BFHI Status

	No BFHI designation or previous designation (n = 73)	Active or emerging BFHI status (n = 68)	p-Value
Policies
Handling breast milk	69 (95)	63 (93)	0.738
Training staff on support skills	60 (82)	60 (88)	0.314
Documentation about feeding	64 (88)	58 (85)	0.680
Rooming in	28 (38)	23 (34)	0.576
Exclusive breastfeeding	40 (55)	38 (56)	0.897
Human milk alternatives available	55 (75)	53 (78)	0.716
Support practices
Breastfeeding conversations prior to birth	52 (71)	55 (81)	0.181
Breastfeeding plans for high-risk pregnancies	34 (47)	38 (56)	0.269
Communicate medical benefits of breastfeeding	55 (75)	62 (91)	0.012^*
Initiate breastfeeding early	62 (85)	63 (93)	0.149
Assess milk supply	55 (75)	61 (90)	0.026^*
Encourage skin to skin	63 (86)	64 (94)	0.121
Encourage kangaroo care	59 (81)	53 (78)	0.672
Avoid pacifiers	28 (38)	35 (51)	0.118
Lactation maintenance despite infant separation	64 (88)	61 (90)	0.703
Supply hospital-grade pumps	58 (79)	54 (79)	0.995
Postdischarge breastfeeding support	57 (78)	55 (81)	0.681

p < 0.05.

BFHI, Baby-Friendly Hospital Initiative; NICU, neonatal intensive care unit.

Table 3.

Sensitivity Analysis Examining Breastfeeding Policies and Practices by Baby-Friendly Hospital Initiative Status without Emerging Status or Previous Status

	No BFHI designation (n = 71)	Active BFHI status (n = 48)	p-Value
Policies
Handling breast milk	67 (94)	48 (100)	0.147
Training staff on support skills	59 (83)	43 (90)	0.321
Documentation about feeding	62 (87)	43 (90)	0.707
Rooming in	26 (37)	15 (31)	0.545
Exclusive breastfeeding	39 (55)	24 (50)	0.597
Human milk alternatives available	53 (75)	38 (79)	0.569
Support practices
Breastfeeding conversations prior to birth	51 (72)	40 (83)	0.147
Breastfeeding plans for high-risk pregnancies	32 (45)	26 (54)	0.33
Communicate medical benefits of breastfeeding	53 (75)	46 (96)	0.002^*
Initiate breastfeeding early	60 (85)	45 (94)	0.125
Assess milk supply	54 (76)	43 (90)	0.062
Encourage skin to skin	61 (86)	46 (96)	0.12
Encourage kangaroo care	57 (80)	39 (81)	0.896
Avoid pacifiers	28 (39)	23 (48)	0.359
Lactation maintenance despite infant separation	62 (87)	45 (94)	0.357
Supply hospital-grade pumps	56 (79)	37 (77)	0.817
Postdischarge breastfeeding support	55 (77)	42 (88)	0.167

p < 0.05.

BFHI, Baby-Friendly Hospital Initiative.

Among all 259 respondents (BFHI: 68/102 [67%], non-BFHI: 73/157 [47%]), Baby-Friendly status was significantly associated with having specific breastfeeding practices in the NICU (67% versus 47%, p = 0.001).

Breastfeeding policies

More than half (n = 141) of respondents who answered the initial NICU survey question reported having specific policies used to support breastfeeding in the NICU. As displayed in Table 2, respondents from BFHI facilities compared with non-BFHI facilities reported policies having human milk alternatives available (78% versus 75%), encouraging exclusive breastfeeding (56% versus 55%), encouraging rooming in (34% versus 38%), requiring documentation around feeding (85% versus 88%), training staff on support skills (88% versus 82%), and training staff on handling breast milk (93% versus 95%). Alternatives to mother’s milk are defined as pasteurized human donor milk, and exclusive breastfeeding refers to the provision of breast milk. There were no significant differences by BFHI status in reported breastfeeding policies by BFHI status.

Breastfeeding practices

A total of 141 of the 259 respondents reported having specific breastfeeding practices in the NICU. More BFHI compared with non-BFHI respondents reported having postdischarge breastfeeding support (81% versus 78%), supplying hospital grade pumps (79% versus 79%), providing lactation maintenance despite infant separation (90% versus 79%), avoiding pacifiers (51% versus 38%), encouraging kangaroo care (78% versus 81%), encouraging skin to skin (94% versus 86%), assessing milk supply (90% versus 75%), initiating breastfeeding early (93% versus 85%), communicating the medical benefits of breastfeeding (91% versus 75%), creating breastfeeding plans for mothers with high-risk pregnancies (56% versus 47%), and starting breastfeeding conversations with parents prior to birth (81% versus 71%). Authors let facilities define kangaroo care and skin-to-skin practices. The only statistically significant differences were that BFHI compared with non-BFHI facilities had higher percentages assessing milk supply (90% versus 75%, p = 0.026) and communicating the medical benefits of breastfeeding (91% versus 75%, p = 0.012) (Table 2).

Sensitivity analysis

A sensitivity analysis was performed to determine whether findings changed after the removal of facilities that were in the process of obtaining BFHI status and facilities that had prior BFHI status that was not renewed. Facilities with an existing BFHI designation alone (n = 223) remained significantly associated with having specific breastfeeding practices in the NICU (70% versus 46%, p = 0.001). Notably, 100% of respondents at Baby-Friendly facilities reported having milk handling policies under the sensitivity analysis compared with 93% in the original analysis. BFHI-established status remained significantly associated with communicating the medical benefits of breastfeeding (p = 0.002). Differences by BFHI status regarding assessing milk supply, however, were no longer significant (p = 0.062).

Discussion

This cross-sectional study of 259 hospitals explored differences in breastfeeding support practices and policies in NICUs across the United States by BFHI status. BFHI status was significantly associated with having specific breastfeeding practices in the NICU. BFHI hospitals were more likely to (1) assess the milk supply of mothers and (2) communicate the medical benefits of breastfeeding to parents. There were no additional differences among the other breastfeeding support policies and practices by BFHI status. Given that there is limited evidence on breastfeeding support practices and policies in the NICU that influence human milk consumption, these findings highlight ways in which non-BFHI facilities can improve on assessing mother’s milk supply and communicating the medical benefits of breastfeeding. These findings also highlight areas in which BFHI facilities without specific NICU breastfeeding support practices and policies can focus improvements.

The “Ten Steps to Successful Breastfeeding” (Ten Steps) is a framework that guides the BFHI and a set of guidelines that hospitals are required to adhere to in order to receive the BFHI designation.¹⁷ The Ten Steps require facilities to support parents to initiate breastfeeding as soon as possible after birth, but there remains a gap for specific guidance related to high-risk settings. Although there is limited evidence on the influence of BFHI in the NICU specifically, a prospective study examining factors associated with breastfeeding in NICUs found that early initiation of pumping, a practice that is encouraged with the Ten Steps, may increase breastfeeding rates.¹⁸ Our findings are consistent with existing literature suggesting the Ten Steps improve the assessment of mother’s milk supply in the NICU.¹⁹ These findings are in line with a recent study reporting that adherence to the Ten Steps was found to be higher among BFHI hospitals.²⁰ A multidisciplinary study found that significant improvements were attained in the percentages of mothers who expressed milk within 6 hours of delivery in the NICU when the Ten Steps program was implemented.²¹ Existing literature demonstrates that there are conflicting findings on the topic of breastfeeding support interventions. A systematic review of global evidence found that structured programs such as BFHI can improve both breastfeeding initiation and duration.¹⁵ However, an evidence review of interventions intended to support breastfeeding by the U.S. Preventative Services Task Force favored individual-level interventions as effective at improving breastfeeding.²² Nonetheless, global evidence from an earlier systematic review suggests that structured programs such as BFHI positively affect initiation and duration of breastfeeding.¹³

The findings of this study may also help reduce socioeconomic and racial disparities in breastfeeding within the NICU. Prior studies have indicated that the NICU is a missed opportunity to address poverty due to how it comprised disproportionately low-income families.²³ Moreover, rates of breastfeeding tend to be much lower among women from low-income families than those from higher-income families.²⁴ In a survey assessing breast milk consumption in NICUs across the United States, the median prevalence of neonates receiving breast milk was 75%; however, the percentage was higher in postal codes with fewer Black residents (80%) and lower in postal codes with more Black residents (72%), indicating a substantial disparity by race.²⁵ In a multistate analysis, Hawkins et al. found that BFHI was effective at increasing breastfeeding initiation and duration among mothers with lower levels of education.²⁶ Breastfeeding disparities by race between Black and White infants have widened between 2009 and 2015 despite improvements in breastfeeding within each racial group.²⁷ The percentage of having any breastfeeding practices for the NICU in this survey was low, both for BFHI and non-BFHI hospitals, 67% and 47%, and that more NICUs need to develop breastfeeding practices. Additionally, the percentage of creating breastfeeding plans for mothers with high-risk pregnancies was low, 56% and 47%, and should be increased. Improving quality of care in NICUs can be an important contributor to closing this disparity among vulnerable neonatal populations.²⁸

There are limitations to this analysis worth noting. First, at the time of data collection, BFHI did not have NICU-specific guidelines. However, BFHI released a specific guide to assist NICUs in developing and strengthening policies and support practices for breastfeeding and breast milk consumption in the NICU called the neo-BFHI in 2021.²⁹ The findings from this analysis are in alignment with the recommendations in the neo-BFHI toolkit. As a result, this analysis may provide baseline information for future studies assessing the extent to which neo-BFHI has led to any potential changes in breastfeeding support policies and practices. Second, since this study was carried out in fall of 2019 and was ended early due to the pandemic in early spring 2020, it did not assess how COVID-19 might have influenced policies and practices. Third, the analysis focused solely on the policies and practices in place in the NICU by BHFI status but did not assess actual breastfeeding rates. Lastly, the low response rate for the NICU portion of the data (20%) limits the generalizability of these findings. The authors did not ask whether the facility had a NICU but instead asked whether the NICU has breastfeeding policies and practices in place. It is worth mentioning that since there are much fewer NICUs than general birthing facilities, it is possible that the response rate is not as low as 20%. The COVID-19 pandemic affected the response rate since follow-up with nonresponding hospitals was stopped earlier than planned. Nonetheless, there was equal representation of BFHI and non-BFHI hospitals in all regions of the country due to the use of stratified sampling. When considering the NICU portion of the survey, “encouraging exclusive breastfeeding” could have been written better as “exclusive human milk feeding,” due to not all infants in the NICU being able to breastfeed. This could explain why only 55% of administrators answered that there was a policy encouraging exclusive breastfeeding. Similarly, promoting NICU rooming in is a challenge in the United States, as most NICUs were not designed to have single-family rooms where a breastfeeding parent could stay 24 hours a day. This may explain why only 36% of administrators answered that there was a policy to encourage rooming in. It is likely that responses to this question were driven by the architecture of the NICU rather than the facility’s policies on providing parents with unrestricted access to their infant. The survey could have asked about the fortification of milk, number of births, and the level of care that the NICU provides. Additionally, at the time of the survey, new evidence about the use of pacifiers in the NICU shortening hospitalization times and not leading to worse breastfeeding outcomes was not yet available.³⁰

There are numerous benefits of breastfeeding for vulnerable infants who are admitted to the NICU. This study found that BFHI and non-BFHI hospitals alike had a wide range of breastfeeding support policies and practices in place, but both had room for improvement. Considering the significant differences in assessing milk supply and communicating the medical benefits of breastfeeding, hospitals that have not pursued BFHI status have the opportunity to target their promotion of breastfeeding in the NICU by engaging with parents through assessing milk supply of mothers and communicating the benefits of breastfeeding. Future research should build upon hospital administrator perspectives and explore differences in actual policies and practices and associations with breastfeeding rates within NICUs to provide additional breastfeeding support to vulnerable infants.

Footnotes

Authors’ Contributions

A.R.: Conceptualization (supporting), methodology (lead), formal analysis (lead), writing—original draft (lead), and writing—reviewing and editing (equal). S.G.-N.: Investigation (lead) and writing—reviewing and editing (equal). S.B.-N.: Conceptualization (lead), writing—reviewing and editing (equal), and supervision (lead).

Disclosure Statement

The authors have indicated that they have no competing interests and no personal financial interests to disclose. The authors have indicated no employment that may gain or lose financially from publication of the article.

Funding Information

This study was supported by a grant from the W.K. Kellogg Foundation (P0131072). The W.K. Kellogg Foundation had no role in the design and conduct of the study.

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