TABLE 1

Overview of Ten Steps With Study Criteria and Baseline Study Findings

Step DefinitionStudy CriteriaAreas Hospitals Doing Well in at Start of ProjectMost Commonly Reported Barriers to Meeting Step/Quality Gaps Identified
1. Have a written breastfeeding policy that is routinely communicated to all health care staff.Hospital had written breastfeeding policy that was communicated to all staff.All hospitals had written breastfeeding policy in place.Not all hospitals routinely communicated the policy to their staff, and policies were often inadequate in addressing the 10 model steps.
2. Train all health care staff in skills necessary to implement this policy.Eighty percent of all health care staff had received the recommended amount of breastfeeding education: nurses, 20 h; physicians, 3 h.Thirteen hospitals had ≥80% nursing staff trained. One hospital developed evening session for physicians with >90% attendance.Physician education remained a significant obstacle in most hospitals (including those already BFHI certified) and nursing staff education in 7 hospitals.
3. Inform all pregnant women about the benefits and management of breastfeeding.All mothers were informed of the benefits and management of breastfeeding.Prenatal education classes often included breastfeeding education.Despite presence of prenatal education classes, almost all hospitals reported ≤25% mothers attended. Most hospitals did not have system in place for ensuring all women were informed.
4. Help all mothers initiate breastfeeding within 1 h of birth and encourage skin-to-skin contact in the first half hour.All babies were placed skin-to-skin within 30 min after delivery and allowed to stay there for at least 1 hour until first breastfeed occurred.Most hospitals provided prompt and consistent skin-to-skin contact after delivery.Skin-to-skin after cesarian delivery was limited at most hospitals.
5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.All mothers are shown how to breastfeed and maintain lactation even if separated from their infant. Pumping begins within 6 h of separation.Almost all hospitals achieved this step.Some nurses delayed initiating pumping >6 h in cases of mother-baby separation.
6. Give infants no food or drink other than breast milk unless medically indicated.No routine supplementation of breastfed infants with formula, and mothers are educated on potential negative consequences of using formula without medical indication. Hospital must buy its own formula, and no formula advertising should be present in care settings.Some hospitals had physician orders for formula. One had a written consent form for supplementation.Nonmedically indicated supplementation with formula was widespread, occurring most often at mother’s request. Many hospitals were not purchasing own formula, and 25% were still handing out formula discharge packs.
7. Practice “rooming in”: allow mothers and infants to remain together 24 h a day.Babies are kept with their mothers 24 h a day with exception of 1 hour for medical procedures. Mothers are educated on rationale for rooming-in when asking for babies to be taken to the nursery.Some hospitals promoted naptime to encourage daytime rest. One hospital used written instructions and parental signature when removing infant from room.Many hospitals reported difficulty implementing this step, primarily at night.
8. Encourage unrestricted breastfeeding.Mothers are encouraged to breastfeed without limits on time and taught to feed on cue.Almost all hospitals reported achieving this step.Medical charting included feeding time duration.
9. Give no pacifiers or artificial nipples to breastfeeding infants.Standard bottle and nipple is not first or second choice for supplementing. Mothers educated on potential negative consequences of artificial nipple use.All hospitals reported that pacifiers were not routinely given to breastfeeding infants.More than half of hospitals provided pacifiers when requested by mother and/or reported that bottle feeding was first or second choice for supplementing.
10. Foster the establishment  of breastfeeding support groups and refer mothers to them on discharge.Mothers are routinely offered breastfeeding support after discharge.Many hospitals had regular mother-support groups on hospital unit.Extent of outpatient breastfeeding support varied, with some very limited.