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Service Delivery Innovation Profile

Baby-Friendly Hospital Initiative Leads to Sustained Increases in Breastfeeding Among Low-Income Whites and Minorities

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Boston Medical Center, an inner-city academic medical center serving primarily low-income, minority patients, was one of the first U.S. hospitals to adopt the Baby-Friendly™ Hospital Initiative. This initiative, developed by the United Nations Children’s Fund and the World Health Organization, outlines 10 steps that support the initiation of breastfeeding. Random medical record reviews show that the program has led to sustained increases in breastfeeding initiation rates at the hospital in both white and minority populations. In addition, other hospitals that have become Baby-Friendly have breastfeeding rates that are well above the national average.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of breastfeeding initiation rates obtained through random medical chart review.
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Developing Organizations

Boston Medical Center
Boston, MAend do

Date First Implemented

Implementation began in 1997; Boston Medical Center received the Baby-Friendly™ designation in 1999.begin pp

Patient Population

Gender > Female; Age > Newborn (0-1 month); Vulnerable Populations > Racial minorities; Urban populations; Womenend pp

Problem Addressed

Although breast milk is considered the optimal form of nutrition for infants and young babies, breastfeeding rates in the United States are suboptimal, especially among certain ethnic and socioeconomic groups. Successful initiation of breastfeeding can promote continued breastfeeding among all women, including those in minority, poor, and immigrant families.
  • Breastfeeding is beneficial and recommended: Infants who are not breastfed may have increased rates of otitis media, gastroenteritis, and respiratory tract infections; slower brainstem maturation; and, eventually, higher rates of obesity and type 1 and type 2 diabetes.1,2 Due to these benefits, the American Academy of Pediatrics states that "exclusive breastfeeding is sufficient to support optimal growth and development for approximately the first 6 months of life" and should be continued for 1 year or more with the addition of complementary foods.3 Healthy People 2010 breastfeeding goals (which are designated by the U.S. Department of Health and Human Services) include having 75 percent of new mothers initiate breastfeeding, 50 percent breastfeed at 6 months, and 25 percent breastfeed at 1 year.4
  • U.S. breastfeeding rates are suboptimal: In 2006, only 74 percent of U.S. mothers initiated breastfeeding, 43 percent breastfed at 6 months, and 23 percent continued breastfeeding at 1 year; approximately 33 percent of infants born in 2006 were exclusively breastfed through 3 months of age, and less than 14 percent were exclusively breastfed for 6 months.5 These suboptimal rates are due in part to the strong influence of formula manufacturers in the United States and to the lack of knowledge among clinicians about the benefits of breastfeeding and how to encourage new mothers to initiate breastfeeding.
  • Minorities and low-income women are least likely to breastfeed: Breastfeeding rates among non-Hispanic black women were only 65 percent in 2005 to 2006; furthermore, breastfeeding rates in 1999 to 2006 were 74 percent among mothers with higher income but only 57 percent among those with lower income.6 The same disparities existed at Boston Medical Center (which primarily serves low-income minority patients), where a 1995 analysis of newborn discharges found that only 6 percent of new mothers were exclusively breastfeeding and less than 60 percent were partially breastfeeding. By contrast, breastfeeding initiation rates in higher-income areas surrounding Boston were above 80 percent.

What They Did

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Description of the Innovative Activity

Boston Medical Center implemented the “Ten Steps to Successful Breastfeeding” as designated by the Baby-Friendly Hospital Initiative; the medical center also refuses to accept free formula, another requirement for achieving Baby-Friendly™ designation. A description of the program is as follows:
  • Adopting the program's 10 steps: The 10 steps of the program were adopted by the medical center as described below:
    • Have a written breastfeeding policy that is routinely communicated to all health care staff: The medical center designed a policy that outlined the 10 steps; the policy is communicated to staff as part of training and nursing competency requirements (see below for more details).
    • Train all health care staff in skills necessary to implement the policy: A pediatrician provides education about breastfeeding and the Baby-Friendly program via presentations to pediatricians and obstetricians during grand rounds. The pediatrician also holds monthly training sessions with residents, interns, and medical students on the postpartum unit and the neonatal intensive care unit (NICU). A lactation consultant and two pediatric nurse educators provide comprehensive education to nurses on an ongoing basis. In addition, many staff members have attended a 5-day breastfeeding course offsite. Finally, senior administrators and other employees, including cleaning staff, interpreters, telephone operators, and unit secretaries, were presented with an educational program called “Reach and Teach,” which includes slides and a short video addressing the health benefits of breastfeeding and information about the Baby-Friendly initiative.
    • Inform all pregnant women about the benefits of breastfeeding: Physicians and nurses leverage opportunities to highlight the benefits of breastfeeding to pregnant women on admission and throughout their hospital stay. In addition, breastfeeding is highlighted in prenatal classes held at the hospital. Written materials are also distributed, but this approach is considered secondary to oral communication about the value of breastfeeding.
    • Help mothers initiate breastfeeding within 1 hour of birth: Babies are placed skin-to-skin on the mother's chest immediately after birth, rather than taken away for weighing, measuring, a vitamin K shot, and other care. (These tasks do not need to be performed immediately after birth.) Babies are put skin-to-skin with the mother to take advantage of the newborn’s initial alertness and natural instinct to begin breastfeeding. The goal is not to interfere with the natural course of events. When necessary, labor and delivery nurses offer positive reinforcement, helping mothers hold their babies and coaching them on how to help the baby latch onto the breast.
    • Show mothers how to breastfeed and how to maintain lactation, even when they are separated from their infants: This step is particularly important for sick infants who may be separated from their mothers and placed in the NICU at birth. All medical center nursing staff, doulas, and peer counselors who assist lactation consultants are trained to assist women in the use of pumps, and the Pumps for Peanuts program provides electric breast pumps to mothers with infants in the NICU if their insurance does not cover the cost of a breast pump.
    • Give newborn infants no food or drink other than breast milk (unless medically indicated): If the baby is given the breast and nothing else, the baby will be much more likely to breastfeed successfully.
    • Encourage breastfeeding on demand: Although feeding babies on a set schedule (e.g., every 4 hours) may facilitate hospital routines, it does not accommodate an individual baby’s instincts, because most do not want to feed at regular intervals. Mothers are taught to learn and respond to their infant’s hunger cues.
    • Practice “rooming-in,” allowing mothers and infants to remain together 24 hours a day: Rooming-in facilitates feeding on demand. Infants spend almost no time in the nursery, and all examinations are performed in the mother’s room.
    • Give no bottles or pacifiers to breastfeeding infants: The medical center eliminated the routine distribution of pacifiers on the postpartum unit, as any sucking done by the baby should lead to obtaining nutrition, and use of pacifiers may prevent babies from learning to breastfeed properly. Bottlefeeding and the use of bottle nipples are also discouraged to the extent possible, because formula supplementation is rarely needed and interferes with breastfeeding.
    • Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic: The medical center's lactation consultant holds thrice-weekly breastfeeding classes to provide education and support. In addition, the medical center provides a telephone support line (617-414-MILK) and employs a peer counselor (a woman who has breastfed her own children) to work with mothers before and after hospital discharge. The number of peer counselors at any given time depends on funding.
  • Forgoing free formula: The medical center refuses to accept free formula and related products from formula manufacturers and instead pays for the formula it provides to requesting patients. The hospital has also eliminated the distribution of free formula samples to new mothers at discharge. Adoption of these policies is also required for Baby-Friendly designation.
  • Promoting convenience: To encourage breastfeeding on demand, the medical center opened four breastfeeding/breast pumping rooms so that women who prefer privacy can breastfeed easily.

Context of the Innovation

Boston Medical Center is a nonprofit, academic medical center located in inner-city Boston that handles approximately 2,500 live births per year. Many patients are low income and/or minorities; roughly one-half are African American and one-fourth are Hispanic. As noted earlier, a 1995 analysis found that relatively few new mothers at Boston Medical Center were initiating breastfeeding. At that time, the medical center had no lactation staff, facilities, educational programs, or followup services for breastfeeding women. A few medical center nurses had been trying to improve breastfeeding rates, but they were having limited success due to the lack of institutional support. These nurses pushed for adoption of the Baby-Friendly initiative as a way to enhance breastfeeding rates by providing important knowledge to low-income, minority women. The Baby-Friendly Hospital Initiative was developed by the United Nations Children’s Fund and the World Health Organization in 1991 to improve worldwide breastfeeding rates. Baby-Friendly designation is conferred on hospitals or birthing centers that demonstrate compliance with the 10 steps outlined previously. As of 1999 (the year Boston Medical Center achieved Baby-Friendly™ status), only 22 of the more than 16,000 Baby-Friendly™ sites worldwide were located in the United States; by May 2011, that figure had increased to 110 U.S.-based sites (out of more than 19,000 total sites worldwide).

Did It Work?

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Boston Medical Center researchers have performed ongoing studies to evaluate the initiative; Baby-Friendly status has led to significant and sustained increases in rates of breastfeeding initiation and exclusivity at the medical center in both white and minority populations (including for NICU babies). In addition, other hospitals adopting the Baby-Friendly Hospital Initiative demonstrate above-average breastfeeding rates.

Results From Boston Medical Center
  • Increase in overall breastfeeding initiation rates: A review of 200 randomly selected medical records from three different years (before, during, and after implementation) found that the breastfeeding initiation rate at the medical center increased from 58 percent (1995) to 77.5 percent (1998) to 86.5 percent (1999); corresponding figures among African-American women were 34, 64, and 74 percent. Furthermore, the percentage of infants who were exclusively or mostly breastfed (defined as being breastfed for at least 50 percent of feedings) increased from 30 percent in 1995 to 59 percent in 1998, and then to 73 percent in 1999.
  • Increase in NICU breastfeeding initiation rate: The program led to substantial increases in breastfeeding initiation rates among NICU infants.
    • One-week-old infants: The breastfeeding initiation rate (with initiation defined as an infant receiving any breast milk during the first week of feedings in the NICU) increased from 34.6 percent in 1995 to 74.4 percent in 1999; among African Americans, the rate increased from 34.5 to 64 percent.
    • Two-week-old infants: The percentage of 2-week-old infants receiving any amount of breast milk rose from 27.9 to 65.9 percent, and the percentage of those receiving exclusively breast milk rose from 9.3 to 39 percent.
    • Six-week-old infants: In 1995, only one out of eight infants remaining in the NICU at 6 weeks was breastfeeding; in 1999, six of nine 6-week-old infants in the NICU were breastfeeding.
  • Breastfeeding initiation rates sustained: A review of 200 randomly selected medical records was conducted in 2000 and 2001. The analysis indicated that breastfeeding initiation rates remained high—82 percent in 2000 and 87 percent in 2001. The percentage of infants mostly or exclusively breastfed also remained high (67 percent in both years), as did breastfeeding rates among African-American mothers (77 percent in 2000 and 69 percent in 2001). In 2007, based on a random review of 200 charts, breastfeeding initiation rates were 91 percent.
Results From Other Institutions
  • Above-average breastfeeding initiation rates at other hospitals: A 2001 analysis of breastfeeding data gathered from 28 of 29 U.S. hospitals that had received Baby-Friendly designation revealed a mean breastfeeding initiation rate of 83.8 percent, well above the national average of 69.5 percent. The mean rate of exclusive breastfeeding at these hospitals was 78.4 percent, also well above the national average of 46.3 percent.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of breastfeeding initiation rates obtained through random medical chart review.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Creating a task force: A task force was created in September 1997 to pursue Baby-Friendly designation. The task force was chaired by two pediatricians (the chief of ambulatory pediatrics and the director of the newborn nursery) and a pediatric nurse administrator. Eventually, the task force grew to include more than 40 staff members from multiple departments and disciplines. The task force contacted Baby-Friendly USA to obtain resources to pursue Baby-Friendly designation.
  • Writing a policy: The task force wrote a breastfeeding policy to reflect the 10 steps of the program.
  • Educating and training staff: Maternity unit nursing staff underwent a 4-day training program that focused on breastfeeding benefits and techniques. Educational sessions were also held for physicians, residents, interns, medical students, nurses, senior administrators, and other employees.
  • Creating a breastfeeding-friendly environment: At the task force's request, senior leadership agreed to open a breastfeeding and expressing room in a highly visible location in the hospital. Subsequently, three additional rooms were opened.
  • Forgoing free formula: The task force convinced senior leadership to forgo the free formula provided by a formula manufacturer and purchase formula instead.
  • Removing other breastfeeding barriers: Formula manufacturer videotapes, literature, and diaper discharge bags were removed and replaced with Boston Medical Center diaper discharge bags and bassinet cards listing breastfeeding tips.
  • Publicizing the initiative: Posters outlining the 10 steps were printed in multiple languages (English, Spanish, and French Creole) and displayed throughout the hospital.
  • Educating patients: The lactation consultant began teaching weekly breastfeeding classes for mothers in 1998; classes are now held three times a week. A telephone support line and a peer counseling service were also launched in 1998.
  • Facilitating breast pump access: The task force created the previously mentioned Pumps for Peanuts program, a grant-funded initiative that provides electric breast pumps to all mothers with infants in the NICU, regardless of insurance status or ability to pay.

Resources Used and Skills Needed

  • Staffing: Boston Medical Center has lactation coverage 6 days a week by board-certified lactation consultants; lactation consultants were hired in conjunction with becoming Baby-Friendly to handle breastfeeding problems and to train staff. The medical center also has one or two peer counselors at any given time; the number of peer counselors depends on the extent of grant funding available. Although each counselor is paid approximately $12 per hour, peer counseling is more cost-effective than using trained nursing professionals to counsel breastfeeding women in uncomplicated issues; nevertheless, peer counselors are not paid by the hospital and instead are financed via grant funding.
  • Costs: In addition to salaries for the lactation consultants and peer counselors, other program costs include the following:
    • Annual fee: An annual fee ranging from $550 to $900 covers the costs of participating in the program; the fee varies depending on the number of births per year.
    • Training: Staff training costs are not available but vary according to whether training is sought externally or conducted in-house.
    • Breastfeeding rooms: The medical center opened four breastfeeding and expressing rooms at a cost of $2,000 each.
    • Formula costs: Expenses for formula (incurred as a result of forgoing free formula) are less than $20,000 annually.
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Funding Sources

Boston Medical Center
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Tools and Other Resources

Information about the Baby-Friendly initiative, including an information packet and support materials, is available at

Adoption Considerations

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Getting Started with This Innovation

  • Ensure physician and administrative support: Nurses, lactation consultants, and other involved staff members may become discouraged if physicians are not also involved and supportive of breastfeeding promotion and if hospital administration is not prepared to support the initiative.
  • Acknowledge that the initiative will cost money: Build senior leadership support by emphasizing that the initiative will help patients and improve the health of the children.
  • Persuade hospital administrators to pay for infant formula: It can be difficult to convince hospital leadership to pay for something that is otherwise provided for free. However, program advocates should emphasize that formula costs will likely be well below the value of formula currently provided, because successful breastfeeding initiation will vastly reduce the amount of formula needed for newborns. In addition, the ethics of providing a nutritionally inferior free product are increasingly coming under fire, and ethics committees at the hospital may be in favor of this change.
  • Involve prominent staff from all areas of the institution: To ensure a consistent message in support of breastfeeding, involve representatives from pediatrics, obstetrics/gynecology, midwifery, family medicine, nursing, postpartum care, NICU, prenatal services, and nutritional services. It is especially important to solicit the involvement of obstetrics/gynecology staff, as these individuals can help to remove barriers at the time of birth and to ensure that newborns are breastfeeding within 1 hour of birth.

Sustaining This Innovation

  • Plan for increases in lactation support: Although nursing staff will become trained in lactation over time as their experience with breastfeeding women increases, certified lactation consultants may be needed to handle breastfeeding issues as the number of breastfeeding women increases.
  • Be patient: Staff may initially resist change, but, eventually, breastfeeding becomes the norm.
  • Do not be overwhelmed by the enormity of the task: Focus on encouraging breastfeeding with the women who come into the institution, rather than worrying about breastfeeding rates in the community as a whole (which are likely beyond the institution's control). Recognize that not all women will choose to breastfeed, and therefore do not perceive the program to be a "failure" if it does not achieve 100-percent participation.

More Information

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Contact the Innovator

Anne Merewood, PhD, MPH, IBCLC
Associate Professor of Pediatrics
Boston University School of Medicine
Director, The Breastfeeding Center
Boston Medical Center
Division of General Pediatrics
88 East Newton St., Vose 3
Boston, MA 02118
Phone: (617) 414 7902
Fax: (617) 414 2662

Innovator Disclosures

Dr. Merewood has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Philipp BL, Merewood A, Miller LW, et al. Baby-Friendly hospital initiative improves breastfeeding initiation rates in a US hospital setting. Pediatrics. 2001;108(3):677-81. [PubMed]

Philipp BL, Malone KL, Cimo S, et al. Sustained breastfeeding rates at a US Baby-Friendly hospital. Pediatrics. 2003;112(3):e234-6. [PubMed]

Merewood A, Patel B, MacAuley L, et al. Breastfeeding duration rates and factors affecting continued breastfeeding among infants born at an inner-city US Baby-Friendly hospital. J Hum Lact. 2007;23(2):157-64. [PubMed]

Merewood A, Philipp BL. Implementing change: becoming Baby-Friendly in an inner city hospital. Birth. 2001;28:36-40. [PubMed]

Merewood A, Philipp BL, Chawla N, et al. The baby-friendly hospital initiative increases breastfeeding rates in a US neonatal intensive care unit. J Hum Lact. 2003;19(2):166-71. [PubMed]

Merewood A, Mehta SD, Chamberlain LB, et al. Breastfeeding rates in US Baby-Friendly hospitals: results of a national survey. Pediatrics. 2005;116(3):628-34. [PubMed]

Newton KN, Chaudhuri J, Grossman X, et al. Factors associated with exclusive breastfeeding among Latina women giving birth at an inner-city Baby-Friendly Hospital. J Hum Lact. 2009;25(1):28-33. [PubMed]

Saadeh R, Casanovas C. Implementing and revitalizing the Baby-Friendly Hospital Initiative. Food Nutr Bull. 2009;30(2 Suppl):S225-9. [PubMed]

Mydlilova A, Sipek A, Vignerova J. Breastfeeding rates in baby-friendly and non-baby-friendly hospitals in the Czech Republic from 2000 to 2006. J Hum Lact. 2009;25(1):73-8. [PubMed]

Labbok MH. Breastfeeding and Baby-Friendly Hospital Initiative: more important and with more evidence than ever. J Pediatr (Rio J). 2007;83(2):99-101. [PubMed]

Merewood A, Mehta SD, Chamberlain LB, et al. Breastfeeding rates in US Baby-Friendly hospitals: results of a national survey. Pediatrics. 2005;116(3):628-34. [PubMed]

Merten S, Ackermann-Liebrich U. Exclusive breastfeeding rates and associated factors in Swiss baby-friendly hospitals. J Hum Lact. 2004;20(1):9-17. [PubMed]

Weng DR, Hsu CS, Gau ML, et al. Analysis of the outcomes at baby-friendly hospitals: appraisal in Taiwan. Kaohsiung J Med Sci. 2003;19(1):19-28. [PubMed]


1 American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2005 Feb;115(2):496-506. [PubMed] Available at (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
2 Merewood A, Philipp BL, Chawla N, et al. The baby-friendly hospital initiative increases breastfeeding rates in a US neonatal intensive care unit. J Hum Lact. 2003;19(2):166-71. [PubMed]
3 American Academy of Pediatrics. Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 1997;100:1035-9. [PubMed]
4 U.S. Department of Health and Human Services. Healthy People 2010: Conference Edition, I and II. Washington, DC: Department of Health and Human Services, Public Health Service, Office of the Assistant Secretary for Health; 2000.
5 U.S. Centers for Disease Control and Prevention. Breastfeeding Among U.S. Children Born 1999-2006, CDC National Immunization Survey. Available at:
6 National Center for Health Statistics. NCHS Data Brief Number 5. Breastfeeding in the United States: Findings from the National Health and Nutrition Examination Survey, 1999-2006. April 2008. Available at:
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: September 15, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 27, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 18, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.