title: Do baby-friendly hospitals influence breastfeeding duration on a national level?
abstract: OBJECTIVE
  In Switzerland, the Baby-Friendly Hospital Initiative (BFHI) proposed by the United Nations Children's Fund (UNICEF) was introduced in 1993 to promote breastfeeding nationwide. This study reports results of a national study of the prevalence and duration of breastfeeding in 2003 throughout Switzerland and analyzes the influence of compliance with UNICEF guidelines of the hospital where delivery took place on breastfeeding duration.
  
  
  METHODS
  Between April and September 2003, a random sample of mothers who had given birth in the past 9 months in Switzerland received a questionnaire on breastfeeding and complementary feeding. Seventy-four percent of the contacted mothers (n = 3032) participated; they completed a 24-hour dietary recall questionnaire and reported the age at first introduction of various foods and drinks. After excluding questionnaires with missing information relevant for the analyses, we analyzed data for 2861 infants 0 to 11 months of age, born in 145 different health facilities. Because it was known whether each child was born in a designated baby-friendly hospital (45 hospitals) or in a health facility in the process of being evaluated for BFHI inclusion (31 facilities), we were able to assess a possible influence of the BFHI on breastfeeding success. For this purpose, we merged individual data with hospital data on compliance with the UNICEF guidelines, from a data source collected on an annual basis for quality monitoring of designated baby-friendly hospitals and health facilities in the evaluation process. Information on actual compliance with the guidelines allowed us to investigate the relationship between breastfeeding outcomes and compliance with UNICEF guidelines. We were also able to compare the breastfeeding results with those for non-baby-friendly health facilities. The comparison was based on median durations of exclusive, full, and any breastfeeding calculated for each group. To allow for other known influencing factors, we calculated adjusted hazard ratios by using Cox regression; we also conducted logistic regression analyses with the 24-hour dietary recall data, to calculate adjusted odds ratios for validation of results from the retrospectively collected data.
  
  
  RESULTS
  In 2003, the median duration of any breastfeeding was 31 weeks at the national level, compared with 22 weeks in 1994, and the median duration of full breastfeeding was 17 weeks, compared with 15 weeks in 1994. The proportion of exclusively breastfed infants 0 to 5 months of age was 42% for infants born in baby-friendly hospitals, compared with 34% for infants born elsewhere. Breastfeeding duration for infants born in baby-friendly hospitals, compared with infants born in other hospitals, was longer if the hospital showed good compliance with the UNICEF guidelines (35 weeks vs 29 weeks for any breastfeeding, 20 weeks vs 17 weeks for full breastfeeding, and 12 weeks vs 6 weeks for exclusive breastfeeding). To control for differences in the study population between the different types of health facilities, hazard and odds ratios were calculated as described above, taking into account socioeconomic and medical factors. Although the analysis of the retrospective data showed clearly that the duration of exclusive and full breastfeeding was significantly longer if delivery occurred in a baby-friendly hospital with high compliance with the UNICEF guidelines, whereas this effect was less prominent in other baby-friendly health facilities, this difference was less obvious in the 24-hour recall data. Only for the duration of any breastfeeding could a positive effect be seen if delivery occurred in a baby-friendly hospital with high compliance with the UNICEF guidelines. Known factors involved in the evaluation of baby-friendly hospitals showed the expected influence, on the individual level, on duration of exclusive, full, and any breastfeeding. If a child had been exclusively breastfed in the hospital, the median duration of exclusive, full, and any breastfeeding was considerably longer than the mean for the entire population or for those who had received water-based liquids or supplements in the hospital. A positive effect on breastfeeding duration could be shown for full rooming in, first suckling within 1 hour, breastfeeding on demand, and also the much-debated practice of pacifier use. After controlling for medical problems before, during, and after delivery, type of delivery, well-being of the mother, maternal smoking, maternal BMI, nationality, education, work, and income, all of the factors were still significantly associated with the duration of full, exclusive, or any breastfeeding.
  
  
  CONCLUSIONS
  Our results support the hypothesis that the general increase in breastfeeding in Switzerland since 1994 can be interpreted in part as a consequence of an increasing number of baby-friendly health facilities, whose clients breastfeed longer. Nevertheless, several alternative explanations for the longer breastfeeding duration for deliveries that occurred in baby-friendly hospitals can be discussed. In Switzerland, baby-friendly hospitals actively use their certification by UNICEF as a promotional asset. It is thus possible that differences in breastfeeding duration are attributable to the fact that mothers who intend to breastfeed longer would choose to give birth in a baby-friendly hospital and these mothers would be more willing to comply with the recommendations of the UNICEF guidelines. Even if this were the case, however, this selection bias would not explain the differences in breastfeeding duration between designated baby-friendly health facilities with higher compliance with the UNICEF guidelines and those with lower compliance. Especially this last point strongly supports a beneficial effect of the BFHI, because mothers do not know how well hospitals comply with the UNICEF program. The fact that breastfeeding rates have generally improved even in non-baby-friendly health facilities may be indirectly influenced by the BFHI; its publicity and training programs for health professionals have raised public awareness of the benefits of breastfeeding, and the number of professional lactation counselors has increased continuously. Breastfeeding prevalence and duration in Switzerland have improved in the past 10 years. Children born in a baby-friendly health facility are more likely to be breastfed for a longer time, particularly if the hospital shows high compliance with UNICEF guidelines. Therefore, the BFHI should be continued but should be extended to include monitoring for compliance, to promote the full effect of the BFHI.
authors.affiliation: Institute of Social and Preventive Medicine, University of Basel, Basel, Switzerland. sonja.merten@unibas.ch
authors.forename: Sonja
authors.initials: S
authors.lastname: Merten
authors.forename: Julia
authors.initials: J
authors.lastname: Dratva
authors.forename: Ursula
authors.initials: U
authors.lastname: Ackermann-Liebrich
mesh_terms: D001942:Breast Feeding / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence; D006293:Health Promotion; D006761:Hospitals; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D012959:Socioeconomic Factors; D013557:Switzerland; D013997:Time Factors; D014480:United Nations