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MO-07-0032 BFP

Hospitals should promote and support breastfeeding.




1.1 Form an interdisciplinary, culturally appropriate team comprised of hospital staff including; administrators, medical staff, nursing staff, perinatal health educators, lactation specialist/consultants, and registered dietitians. Team members should join together to reduce institutional barriers to breastfeeding, such as mother-infant separation, fragmentation of care and routine supplementation. This team will be responsible for

1.1.1 developing, implementing, and monitoring hospital policies and practices.

1.1.2 ensuring ongoing education for all staff.

1.1.3 performing an evaluation (Word)Opens a new browser window.based on guidelines similar to the Baby-Friendly Hospital Initiative Self Appraisal Tool.2

1.1.4 assuring support for pregnant and breastfeeding patients and hospital staff.






1.1 A multidisciplinary task force can bring a variety of perspectives. 4,8,9,10,19,20







1.1.3 Ongoing evaluation will assist the team in program implementation and planning. 2,6,7,12

1.1.4 Information from local experts and patients using the services will often be helpful.

Position Papers from various disciplines:

Physician Education Resources

Summaries of state, national and international evaluations:

Resources on Change and QI

Sample Evaluation Tools

Resources lists (also see Policy #10)

1.2 Team members should review the International Code of Marketing Breastmilk Substitutes (PDF)Opens a new browser window.

1.2 International concern exists regarding the marketing practices of artificial infant milk manufacturers. Accepting educational grants, teaching materials, gratuities, and gifts from artificial infant milk companies may indirectly endorse artificial infant milk. 1,24,25,26

1.3 The team should designate a member to be responsible for assessing needs, planning and monitoring interventions, implementing, and updating competency-based training in breastfeeding for all staff caring for mothers, infants, and/or children.

1.3 Ongoing training is essential to maintain staff competency. The level of competency required and/or needed should be based on staff functions, responsibilities, and previously acquired training, and should include documentation that essential competencies have been mastered. 3,5,11,13,21,22,23


Staff competencies & logs and staffing recommendations

1.4 All hospital departments serving mothers, infants, and/or children should have written breastfeeding policies (PDF)Opens a new browser window. that are routinely communicated to all health care staff, beginning with hospital orientation.

1.4 Ongoing reinforcement of policies is essential to maintain competence. 17,20

Sample Policies and Protocols:

1.5 Nurses coming in contact with mothers, infants or children should receive standardized education and training on the support and management of lactation. Lactation management should be included as part of orientation and included as part of ongoing training and competency evaluation for both nurses and physicians.

1.5 Training will assist nurses in using common terms and standard recommendations.

Mothers are often confused and frustrated when receiving varying advice. Eighteen hours of education (15 diadactic, 3 clinical) [Link to new Baby Friendly Initiative Courses] is the minimum amount of lactation training recommended by the by the World Health Organization (WHO). 5,11,12


1.6 Hospitals should demonstrate support for breastfeeding by fostering the formation of breastfeeding support groups.

1.6.1 Hospital administration should provide space and/or cover operational costs to support local community lactation support groups or hospital-based breastfeeding support groups.

1.6. Ongoing peer support groups lead to increased success and increased duration of breastfeeding. 15,16,18,23 (note policy #10).

  • Peer Counselors for Breastfeeding Mothers in the Hospital Setting: Trials, Training, Tributes, and Tribulations (Abstract)
  • Bibliography on the value of support groups
  • WIC Breastfeeding Peer Counselor Training Manual

1.7 Hospitals, as employers, should demonstrate support for breastfeeding employees by providing education and assistance to pregnant and lactating staff. Employers should provide a clean, comfortable break space and time to express milk for hospital staff who are breastfeeding mothers and should consider offering

1.7.1 electric breast pumps for hospital staff use.

1.7.2 extended maternity or paternity leave.

1.7.3 on-site child-care for breastfeeding infants of hospital staff.

1.7.4 private space and time for the mother to nurse her baby during breaks.

1.7 Workplace environments that support breastfeeding facilitate continuation of breastfeeding. 20,21,23,25







1.7.4 California state law requires employers to provide a private space other than a toilet stall and a reasonable amount of unpaid time (if it is not concurrent with usual break time) for breastfeeding mothers to express milk. 14


    Policy #1 References:

    1. Armstong, H.& Sokol, E. (1994). The International Code of Marketing of Breast-Milk Substitutes: What it Means for Mothers and Babies World-wide. International Lactation Consultant Association.
    2. Baby-Friendly USA: Baby-friendly Hospital Initiative Self Appraisal Tool (PDF)Opens a new browser window.. Sandwich, MA: Author. (508-888-8044,http://www.babyfriendlyusa.org/eng/index.html)
    3. Berens, P.D. (2001). Prenatal, intrapartum, and postpartum support of the lactating mother. Pediatric Clinics of North America, 48(2), 365-375.
    4. California Department of Health Services. Strategic Plan for Breastfeeding Promotion 2000-2002. (CALDOC No. H900. B74).
    5. Cattaneo, A. & Buzzetti, R. (2001). Effect of rates of breastfeeding of training for the Baby Friendly Hospital Initiative. British Medical Journal, 323, 1358-1362.
    6. DiGirolamo, A. M., Grummer-Strawn, L. M., & Fein, S. (2001). Maternity care practices: Implications for breastfeeding. Birth, 28(2), 1523-1536. PubMed
    7. Durand, M., Labarere, J., Brunet, E. & Pons, J. C. (2003). Evaluation of a training program for healthcare professionals about breastfeeding. European Journal of Obstetrics & Gynecology and Reproductive Biology, 106(2), 134-138
    8. Ellis, D. (1992). Supporting breastfeeding: How to implement agency change. Nurses Association of the American College of Obstetricians and Gynecologist’s (NAACOG’s) Clinical Issues in Perinatal and Women’s Health Nursing, 3, 560-564.
    9. Ellis, D. (1992). The impact of agency policies and protocols on breastfeeding. Nurses Association of the American College of Obstetricians and Gynecologist’s (NAACOG’s) Clinical Issues in Perinatal and Women’s Health Nursing, 3, 553-559.
    10. Hales, D. (1981). Promoting breastfeeding: Strategies for changing hospital policy. Studies in Family Planning, 12(4), 167-172.
    11. Healthy Children 2000 Project (1999). The Curriculum to Support the Ten Steps to Successful Breastfeeding: An 18-hour Interdisciplinary Breastfeeding Management Course for the United States. Sandwich, MA: Health Education Associates.
    12. Korvach, A. C. (1997). Hospital breastfeeding policies in the Philadelphia area: A comparison with the ten steps to successful breastfeeding. Birth, 24(1), 41-48.
    13. Labarere, J., Gelbert-Baudino, N., Ayral, A. S., Duc, C., Berchotteau, M., Bouchon, N., et al. (2005). 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, 115(2), 139-146. Abstract
    14. Labor Code, State of California, Division 2, Part 3, Chapter 3.8, Section 1030-1033.
    15. Locklin, M. & Jansson, M. (1999). Home visits: Strategies to protect the breastfeeding newborn at risk. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 28(1), 33-40.
    16. Moore, E. R., Bianchi-Gray, M., & Stephens, L. (1991). A community hospital-based breastfeeding counseling service. Pediatric Nursing, 17(4), 383-389. PubMed
    17. Mulford, C. (1995). Swimming upstream: Breastfeeding care in a nonbreastfeeding culture. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24, 464-473. Abstract
    18. Page-Goertz, S. (1989). Discharge planning for the breastfeeding dyad. Pediatric Nursing, 15(5), 543-544.
    19. Powers, N. G., Naylor, A. J., Wester, R. A. (1994). Hospital Policies: Crucial to breastfeeding success. Seminars in Perinatology, 18, 517-524.
    20. Reiff, M. I. & Essock-Vitale, S. M. (1985). Hospital influences on early infant-feeding practices. Pediatrics, 76, 872-879. Abstract
    21. Taveras, E., M., Capra, A. M., Braveman, P. A., Jensvold, N. G., Escobar, G. J., & Lieu, T. A. (2003). Clinician support and psychosocial risk factors associated with breastfeeding discontinuation. Pediatrics, 112, 108-115.
    22. Taveras, E. M., Li, R., Grummer-Strawn, L., Richardson, M., Marshall, R., Rego, V. H., et al. (2004). Opinions and practices of clinicians associated with continuation of exclusive breastfeeding. Pediatrics, 113, 283-290.
    23. United States Department of Health and Human Services, Office on Women’s Health. (2000). Breastfeeding: HHS Blueprint for Action on Breastfeeding (PDF)Opens a new browser window.Washington DC: Author.
    24. World Health Organization. (1981). International Code of Marketing of Breast-milk Substitutes (PDF)Opens a new browser window.(Document WHA34/1981/REC/1, Annex 3). Geneva: Author.
    25. World Health Organization. (1990, May 14). (Document WHA Resolution 43.3). Retrieved August 26, 2004, from http://www.ibfan.org/english/resouce/who/whares433.html
    26. World Health Organization. (2001). Infant and Young Child Nutrition (PDF)Opens a new browser window.. (Document WHA54.2. Agenda item 13.1, 18 May 2001). Geneva: Author.

    Additional References:

    AHA Quality Center. Hospitals in Pursuit of Excellence: A Guide to Superior Performance Improvement. American Hospital Association, 2009.
    IOM published six aims for Improvement in health care settings to decrease the number of preventable deaths/harm in hospitals: Care that is safe, timely, effective, efficient, equitable and patient-centered. (STEEEP)
    This report aims to guide health care agencies and hospitals towards quality improvement activities.

    Assistant Secretary of Health: Best Practices Initiative; Baby-Friendly Hospital Initiative Improves Breastfeeding Initiation Rates in U.S. Hospital Setting (Link (PDF)Opens a new browser window.)

    Castrucci, Brian C. MA; Hoover, Kathleen L. MEd, IBCLC; Lim, Suet PhD; Maus, Katherine C. ACSW, LSWA Comparison of Breastfeeding Rates in an Urban Birth Cohort Among Women Delivering Infants at Hospitals That Employ and Do Not Employ Lactation Consultants”; Journal of Public Health Management & Practice. 12(6):578-585, November/December 2006.

    California WIC Association and UC Davis Lactation Center Reports: One Hospital At A Time (2011), Depends On Where You Were Born (2008)

    CDC Breastfeeding Report Card (United States, 2008)

    Chung M, Raman G, Trikalinos T, Lau J, Ip S. Interventions in Primary Care to Promote Breastfeeding: An Evidence Review for the US Preventive Services Task Force. Annals of Internal Medicine, 2008.
    Evidence suggests that breastfeeding interventions are more effective than usual care in increasing short- and long-term breastfeeding rates. Combined pre- and postnatal interventions and inclusion of lay support in a multi-component intervention may be beneficial. (Full Report)

    Declercq E, Labbok M, Sakala C, O’Hara M. Hospital Practices and Women’s Likelihood of Fulfilling Their Intention to Exclusively Breastfeed. American Journal of Public Health, 2009. (Abstract)
    Study sought to assess whether breastfeeding-related hospital practices reported by mothers were associated with achievement of their intentions to exclusively breastfeed.
    Primparas who delivered in hospitals that practices 6 of 7 of the Baby-Friendly steps were 6 times more likely to achieve their intention to exclusively breastfeed than were those in hospitals that practices none or 1 of the steps. Hospitals should implement policies that support breastfeeding with particular attention to eliminating supplementation of health newborns.

    DiGirolamo AM, Grummer-Strawn LM,  Fein SB: Effect of Maternity-Care Practices on Breastfeeding; PEDIATRICS Vol. 122 Supplement October 2008, pp. S43-S49 (Abstract)

    Espuelas C, Paricio-Talayero JM. A Breastfeeding e-Learning Project Based on a Web Forum. Breastfeeding Medicine, 2007. (Abstract)
    Forty two pediatric residents from four hospitals in Spain received a month of intensive theoretical training on breastfeeding, and afterward, they took weekly turns answer parents’ questions in the forum. They completed a pre-post knowledge test and an opinion post-experience and questionnaire with open questions.
    The learning experience was positively evaluated by the participants and contributed to increase their knowledge and skills in breastfeeding issues. We think it is a good method for training future pediatricians on breastfeeding management. In addition, the instrument may contribute to improve lactation knowledge among pediatricians.

    Feldman-Winter L, Schanler R, O’Connor K, Lawrence R. Pediatricians and the Promotion and Support of Breastfeeding. Arch Pediatr Adolesc Med 162(12), 2008. (Abstract)
    A survey of pediatricians on their breastfeeding knowledge, attitudes and practices compared to results from a 1995 study. N=875 pediatricians. Although pediatricians seem better prepared to support breastfeeding, their attitudes and commitment have deteriorated. Personal experience mitigates poor attitudes and seems to enhance breastfeeding practices among those surveyed. Provides evidence for the need to continually enhance pediatricians’ knowledge, attitudes, and practices about breastfeeding. Practical solutions must be developed to improve pediatricians’ beliefs so that mothers can successfully meet their breastfeeding goals.

    Forster D, McLachlan H. Breastfeeding Initiation and Birth Setting Practices: A Review of the Literature. Journal of Midwifery and Women’s Health, 2007. (Abstract)

    Havens DS, Wood SO, Leeman J. Improving Nursing Practice and Patient Care: Building Capacity with Appreciative Inquiry. JONA 36(10) 463-470, October 2006.
    Appreciative inquiry is a philosophy and methodology for promoting positive organizational change. This article describes the theory and ways hospitals are using it.

    Karl, D. J., Beal, J. A., O'Hare, C. M., & Rissmiller, P. N. (2006). Reconceptualizing the nurse's role in the newborn period as an "attacher". MCN Am J Matern Child Nurs, 31(4), 257-262.
    Attachment is a major task for the mother and her newborn; success is associated with positive long term outcomes for mother and child. Article proposes a relational approach to newborn nursing grounded in the principles of attachment theory. Understanding this approach can benefit nurses by bringing a gratifying depth to their practice and benefit mothers and babies.

    Kring D. Research and Quality Improvement: Different Processes, Different Evidence. Medsurg Nursing, 06/2008. (Full article)
    Two sources commonly used for evidence-based practice include research and quality improvement reports. However, they often are implemented improperly. It is important for nurses to distinguish between research and QI. A tool for making such distinction is presented.

    Lawrence M. Noble, Anita Noble, Ivan L. Hand. Cultural Competence of Healthcare Professionals Caring for Breastfeeding Mothers in Urban Areas. Breastfeeding Medicine. December 2009, 4(4): 221-224. doi:10.1089/bfm.2009.0020.

    Manganaro R, Marseglia L, Mamì C, Paolata A, Gargano R, Mondello M, Puliafito A, Gemelli M. Effects of hospital policies and practices on initiation and duration of breastfeeding.  Child Care Health Dev. 2008 Nov 17. (Abstract)

    Mannel R and Mannel RS; Staffing for Hospital Lactation Programs: Recommendations From a Tertiary Care Teaching Hospital. Journal of Human Lactation, 11 2006; vol. 22: pp. 409 - 417.

    Martell, L. K. (2003). Postpartum women's perceptions of the hospital environment. J Obstet Gynecol Neonatal Nurs, 32(4), 478-485. (Abstract)

    Merewood A., Mehta S, Chamberlain, LB, Philipp BL, and Bauchner H,; Breastfeeding Rates in US Baby-Friendly Hospitals: Results of a National Survey, PEDIATRICS Vol. 116 No. 3 September 2005, pp. 628-634 (Abstract)

    Merewood, A., Patel, B., Newton, K. N., MacAuley, L. P., Chamberlain, L. B., Francisco, P., et al. (2007). Breastfeeding duration rates and factors affecting continued breastfeeding among infants born at an inner-city US Baby-Friendly hospital. J Hum Lact, 23(2), 157-164. (Abstract)

    Merten, S., Dratva, J., & Ackermann-Liebrich, U. (2005). Do baby-friendly hospitals influence breastfeeding duration on a national level? Pediatrics, 116(5), e702-708. (Abstract)

    Morton, J. (2008). Breastfeeding Management, Educational Tools for Physicians and Other Professionals: Breastmilk Solutions. www.breastmilksolutions.com/

    Morton, J. (2008). A Premie Needs His Mother: First Steps to Breastfeeding Your Premature Baby [Video]: Breastmilk Solutions. www.breastmilksolutions.com/

    Murray EK, Ricketts S, Dellaport J, :Hospital Practices that Increase Breastfeeding Duration: Results from a Population-Based Study; BIRTH 34:3 September 2007, pp 202-211Colorado study to determine effects of hospital practices on breastfeeding duration and influence of maternal socioeconomic status. Assessed five specific hospital practices: breastfeeding within first hour of life; breastmilk only; infant rooming-in; no pacifier use; and receipt of a telephone number for use after discharge.
    Conclude that the implementation of the five hospital practices supportive of breastfeeding significantly increase breastfeeding duration rates regardless of maternal socioeconomic status.

    Philipp BL., Malone KiL., Cimo S, and Merewood A; Sustained Breastfeeding Rates at a US Baby-Friendly Hospital; PEDIATRICS (electronic version), Sep 2003; 112: 234 - 236. (Full Text (PDF)Opens a new browser window.)

    POWERPOINT PRESENTATION ON: Evidence-Based Breastfeeding Promotion: The Baby Friendly Hospital Initiative (PDF, 1.0 MB)Opens a new browser window.by Rafael Pérez-Escamilla, Ph.D.; Professor of Nutrition, Director, Connecticut Latino Health Disparities NIH EXPORT Center. E-mail: rafael.perez-escamilla@uconn.edu

    Rosenberg KD, Stull JD, Adler MR, Kasehagen LJ, Crivelli-Kovach A.: Impact of Hospital Policies on Breastfeeding Outcomes; Breastfeeding Medicine. June 1, 2008, 3(2): 110-116. (Abstract)

    Stuebe A. The Risks of Not Breastfeeding for Mothers and Infants. Reviews in Obstetrics and Gynecology, 2009.
    For infants, not being breastfed is associated with an increased incidence of infectious morbidity, as well as elevated risks of childhood obesity, type 1 and type 2 Diabetes, leukemia, and sudden infant death syndrome.For mothers, failure to breastfeed is associated with an increased incidence of premenopausal breast cancer, ovarian cancer, retained gestational weight gain, type 2 diabetes, myocardial infarction, and the metabolic syndrome.
    Obstetricians should counsel mothers about the health impact of breastfeeding and ensure that mothers and infants receive appropriate, evidence-based care beginning at birth. Obstetrician should support breastfeeding during antenatal care visit, intrapartum visit, during postpartum hospitalization, at the postpartum visit, and at annual well-women visits.

    Hospital Self-Appraisal Questionnaire (Word)Opens a new browser window.

    Back to Main Page of Breastfeeding Toolkit

    Last modified on: 5/14/2012 4:08 PM