Sir,

In 1991, UNICEF and WHO launched the Baby?Friendly Hospital Initiative with the aim of increasing rates of breastfeeding. “Baby?Friendly” is a designation a maternity site can receive by demonstrating to external assessors compliance with the Ten Steps to Successful Breastfeeding. The Ten Steps are a series of best practice standards describing a pattern of care where commonly found practices harmful to breastfeeding are replaced with evidence based practices proven to increase breastfeeding outcome. Currently, approximately 19 250 hospitals worldwide have achieved Baby?Friendly status, less than 500 of which are found in industrialised nations. The Baby?Friendly initiative has increased breastfeeding rates, reduced complications, and improved mothers' health care experiences. There is a small, quiet revolution going on. An important indicator of good health appears to be rising faster in areas of social deprivation. This may not be unique, but it is certainly unusual. Breastfeeding, which has long been associated with the higher socioeconomic groups in industrialised countries, is now growing rapidly in some of the most socially deprived areas of the UK and USA.

The Royal Oldham Hospital, for example, serves a deprived area to the north east of Manchester in the UK; nearly 30% of its clientele are non?English speakers. In 1994, the town demonstrated the low breastfeeding uptake common to most deprived areas: just 29% of mothers breastfed their babies at birth, and almost all switched to formula in the first 4 weeks. However, 5 years later, breastfeeding initiation had risen to 55% and has since continued to grow steadily, reaching 64% in 2005, while 40% of babies are now still being breastfed at 4 weeks (Val Finigan, Infant Feeding Coordinator, Royal Oldham Hospital, personal correspondence, 27 June 2005).

This dramatic improvement was achieved against a background of unchanging national breastfeeding rates. Data from the quinquennial national infant feeding surveys show no significant increases in English or UK breastfeeding rates since 1980. An exception to this pattern can be found in Scotland, which was the only part of the UK to record a significant increase in breastfeeding duration rates in 2000, with rising prevalence found at all ages up to 9 months.

The difference in Oldham was the hospital trust's far?sighted decision in 1994 to implement the best practice standards necessary for accreditation as Baby?Friendly by UNICEF and the World Health Organization. Scotland's achievement is due to the adoption of breastfeeding strategies by the country's health boards, with Baby?Friendly accreditation as a central component: more than half of Scottish babies are now born in Baby?Friendly hospitals, compared with just 8.6% in England. A similar picture is emerging in the USA. Boston Medical Center (BMC) is an academic teaching hospital, serving primarily minority, poor, and immigrant families living in inner city Boston, MA. In 1997, a group of clinicians concerned about BMC's low breastfeeding rates launched a breastfeeding initiative, which culminated in December 1999 when BMC became the 22nd Baby?Friendly hospital in the USA. Prior to implementation of Baby?Friendly policies, breastfeeding rates at BMC were unimpressive. Leaders of the breastfeeding initiative were aware that impoverished and African American women traditionally had low breastfeeding rates. However, they were more concerned that non?supportive hospital policies and lack of support from health care staff were creating barriers to breastfeeding. They wondered if the problem “was us, not them”. One thing they knew for certain was that every woman wants the best for her baby. Their mission became to create an institution which promotes and supports breastfeeding and see if greater numbers of women would breastfeed, irrelevant of their social status or racial group.

For three challenging years they tore up antiquated policies, said “no thank you” to free formula, and educated one and all about breastfeeding. They believed in their vision, moved forward with baby steps, and refused to take no for an answer. With the Baby?Friendly Initiative Ten Steps to Successful Breastfeeding in place, breastfeeding initiation rates at BMC rose from 58% (1995) to 87% (1999); exclusive breastfeeding rates increased from 6% to 34% and initiation rates among US born black women rose from 34% to 74%.The clinicians learned that if an inner city hospital with few resources and a complex patient population can gain Baby?Friendly accreditation, so can others. In August 2002, BMC's success at raising breastfeeding rates among low income families was recognised with a Best Practice Initiative by the US Department of Health and Human Services.

Achieving Baby?Friendly status: the Ten Steps to Successful Breastfeeding

The first three steps (see table 1) constitute the foundations of good breastfeeding care. Staff education is the central component of the Baby?Friendly program and only with well?trained staff can the necessary practice changes be made. Health professionals who have contact with breastfeeding women need the knowledge and skills to support them to breastfeed successfully. The majority of health professionals in the UK have had little formal education in breastfeeding and commonly lack the practical skills needed to help a mother make enough milk for her baby and feed effectively and without pain. A breastfeeding policy should set out the measurable aims and standards to be achieved and will establish a framework to support and guide staff as they change their practice and provide Baby?Friendly care to mothers. The right of mothers to full information about their care, and support in their chosen feeding method, is integral to the Baby?Friendly approach. For informed choice to function effectively, all pregnant women should receive clear information on the health benefits of breastfeeding and practices which are beneficial to success.

Steps 4 to 9 describe the pillars of good practice necessary for optimum support of breastfeeding mothers. The principles of informed choice are followed, whereby mothers are given accurate information in a timely manner and then supported in their decisions (even if these are not in line with the Ten Steps).

The routine in a Baby?Friendly hospital is for mothers to be given their babies to hold in skin?to?skin contact immediately after birth (or as soon as mother and baby are able). This takes advantage of the alert period in a baby's first hours of life and facilitates a successful first breastfeed. Babies who are put to the breast soon after birth establish breastfeeding faster and breastfeed for a longer duration. Early suckling also significantly increases the concentration of plasma and probably brain oxytocin (“the love hormone”) in the mother, contributing to maternal/infant bonding.

Fundamental to successful breastfeeding is ensuring that mothers know how to hold and attach their babies to the breast, since this is crucial for a good milk supply and pain free feeding. Putting babies to the breast when they indicate they are hungry, and feeding for as long and as often as they want – feeding on demand – is also essential for milk production. Rooming?in permits and encourages breastfeeding on demand. Infants should be breastfed when they demonstrate feeding cues which include hand to mouth activity, smacking lips, rooting, eye movements in light sleep, and movement of extremities. Crying is a late indicator of hunger. A mother cannot respond to a feeding cue if her baby is in a nursery or parked in a cot by the nurses' station. Rooming?in and other Baby?Friendly hospital policies have been shown to increase breastfeeding initiation and duration and enhance maternal?infant bonding.

All breastfeeding mothers should also be taught how to express their milk by hand, a skill which will help to alleviate or avoid common complications such as engorgement. Expressing is also of particular importance for newborn infants separated from their mothers for reasons such as prematurity or illness. Breast milk remains the food of choice for these babies. Therefore, health care staff should provide support and guidance that will assist mothers in establishing and maintaining lactation, and expressing their milk while separated. A mother with an infant in the NICU should be advised and supported to express her milk at least six, and preferably eight or more, times in 24 h including at night. She should also be encouraged to stay with her infant and hold him/her in skin?to?skin contact as much as possible.

According to the AAP, exclusive breastfeeding, which is recommended for the first 6 months of life, is defined as “an infant's consumption of human milk with no supplementation of any type (no water, no juice, no nonhuman milk, and no foods) except for vitamins, minerals, and medications. Exclusive breastfeeding has been shown to provide improved protection against many diseases and to increase the likelihood of continued breastfeeding for at least the first year of life” Mothers should therefore be encouraged to not give their babies food or drink other than breast milk during their first 6 months and hospital staff should ensure that formula supplements are only given where there is a true clinical need. To avoid any risk of confusion in the baby, necessary supplements should be fed by alternative methods appropriate to the baby's condition, such as cup, spoon or syringe, rather than by bottle teat. Similarly, pacifiers can adversely affect breastfeeding in healthy term newborns since time spent sucking on a pacifier is time not spent sucking at mother's breast, and the lack of stimulation can delay the arrival of the full milk supply.

There is no promotion for, or sampling of, infant formula or other breast milk substitutes in a Baby?Friendly hospital which must pay the fair market price for all formula and infant feeding supplies. Distribution of products provided free of charge by commercial interests, such as baby bags made by infant formula manufacturers (regardless of whether they contain formula samples), has been shown to undermine breastfeeding success. UK legislation prohibits formula sampling and free supplies and some other promotion is also illegal, but these issues continue to present a major obstacle to Baby?Friendly implementation in the USA and many other countries.

Good practice is capped off by step 10, which requires that mothers be given information about the support they can access in their communities, such as continuing help with breastfeeding from the health services or mother?to?mother support from voluntary groups. This contact will help maintain mothers' confidence, avoid or solve problems which arise, and increase the duration of breastfeeding.