title: Evaluating the impact of the Baby-Friendly Hospital Initiative on breast-feeding rates: a multi-state analysis.
abstract: OBJECTIVE
  To evaluate the impact of the Baby-Friendly Hospital Initiative (BFHI) on breast-feeding initiation and duration overall and according to maternal education.
  
  
  METHODS
  Quasi-experimental study using data from five states (Alaska, Maine, Nebraska, Ohio, Washington) that participated in the Pregnancy Risk Assessment Monitoring System from 1999 to 2009. Using differences-in-differences models that included year and hospital fixed effects, we compared rates of breast-feeding initiation and duration (any and exclusive breast-feeding for ≥4 weeks) before and after BFHI accreditation between mothers who gave birth in hospitals that were accredited or became accredited and mothers from matched non-BFHI facilities. We stratified analyses into lower and higher education groups.
  
  
  METHODS
  Thirteen BFHI hospitals and nineteen matched non-BFHI facilities across five states in the USA.
  
  
  METHODS
  Mothers (n 11 723) who gave birth in BFHI hospitals and mothers (n 13 604) from nineteen matched non-BFHI facilities.
  
  
  RESULTS
  Although we did not find overall differences in breast-feeding initiation between birth facilities that received BFHI accreditation compared with non-Baby-Friendly facilities (adjusted coefficient = 0·024; 95 % CI -0·00, 0·51), breast-feeding initiation increased by 3·8 percentage points among mothers with lower education who delivered in Baby-Friendly facilities (P = 0·05), but not among mothers with higher education (adjusted coefficient = 0·002; 95 % CI -0·04, 0·05). BFHI accreditation also increased exclusive breast-feeding for ≥4 weeks by 4·5 percentage points (P = 0·02) among mothers with lower education who delivered in BFHI facilities.
  
  
  CONCLUSIONS
  By increasing breast-feeding initiation and duration among mothers with lower education, the BFHI may reduce socio-economic disparities in breast-feeding.
authors.affiliation: 1Boston College,Graduate School of Social Work,McGuinn Hall,140 Commonwealth Avenue,Chestnut Hill,MA 02467,USA.
authors.forename: Summer Sherburne
authors.initials: SS
authors.lastname: Hawkins
authors.affiliation: 2Harvard Kennedy School of Government,Cambridge,MA,USA.
authors.forename: Ariel Dora
authors.initials: AD
authors.lastname: Stern
authors.affiliation: 3Boston College,Chestnut Hill,MA,USA.
authors.forename: Christopher F
authors.initials: CF
authors.lastname: Baum
authors.affiliation: 5Harvard Medical School and Harvard Pilgrim Health Care Institute,Boston,MA,USA.
authors.forename: Matthew W
authors.initials: MW
authors.lastname: Gillman
mesh_terms: D000328:Adult; D001942:Breast Feeding; D002487:Centers for Disease Control and Prevention, U.S.; D004522:Educational Status; D019317:Evidence-Based Medicine; D005260:Female; D006771:Hospitals, Maternity; D006801:Humans; D007231:Infant, Newborn; D008137:Longitudinal Studies; D008297:Male; D016555:Matched-Pair Analysis; D009035:Mothers / Q000193:education; D018673:Nutrition Policy; D010349:Patient Compliance; D062486:Public Health Surveillance; D062211:Spatio-Temporal Analysis; D014480:United Nations; D014481:United States; D014944:World Health Organization
keywords: Breast-feeding; Maternity hospitals; Programme evaluation