Skip Navigation

Strengthen the Evidence for Maternal and Child Health Programs

Sign up for MCHalert eNewsletter

Evidence Tools
MCHbest. Breastfeeding.

MCHbest Logo

Strategy. Hospital Policies

Approach. Promote Baby Friendly policies for hospital systems across the state/jurisdiction

Return to main MCHbest page >>

Overview. Professional support that can be offered to new mothers appear to have a positive effect on their decision to breastfeed. Hospital policy change that increases reporting requirements such as Baby Friendly policies appear to have a positive effect on initiation of breastfeeding as well as on breastfeeding duration and exclusivity.[1,2,3,4,5,6,7,8,9,10]

Evidence. Emerging Evidence. Strategies with this rating typically trend positive and have good potential to work. They often have a growing body of recent, but limited research that documents effects. However, further study is needed to confirm effects, determine which types of health behaviors and conditions these interventions address, and gauge effectiveness across different population groups. (Clarifying Note: The WWFH database calls this "mixed evidence").

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source. (Read more about understanding evidence ratings).

Source. Peer-Reviewed Literature

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Policy. This strategy helps to promote decisions, laws, and regulations that promote public health practices and interventions.
  • Health and Health Behaviors/Behavior Change. This strategy improves individuals' physical and mental health and their adoption of healthy behaviors (e.g., healthy eating, physical activity).
  • Patient Experience of Care. This study improves individuals' perceptions, feelings, and satisfaction with the healthcare services they receive.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Policy Development and Enforcement (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Community-Focused

Examples from the Field. Access descriptions of ESMs that use this strategy directly or intervention components that align with this strategy. You can use these ESMs to see how other Title V agencies are addressing the NPM.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies).

Quadrant 1:
Measuring Quantity of Effort ("What/how much did we do?")

PROCESS MEASURES:

  • Number of hospitals engaged in Baby Friendly policy promotion efforts. (Measures the reach and scale of the initiative across hospital systems.)
  • Number of training sessions provided to hospital staff on Baby Friendly practices. (Quantifies the efforts to build workforce capacity for policy implementation.)
  • Number of hospital departments/units targeted by Baby Friendly policy change (e.g., L&D, postpartum). (Tracks the comprehensiveness of the policy initiative.)

OUTCOME MEASURES:

  • Number of hospitals that achieve Baby Friendly designation after engaging in promotion efforts. (Assesses the ultimate adoption and certification of Baby Friendly policies.)
  • Number of hospital staff who report improved knowledge and attitudes about Baby Friendly practices. (Measures the impact of promotion efforts on workforce readiness.)
  • Number of mothers who receive Baby Friendly supported care in hospitals implementing the policies. (Quantifies the number of patients directly benefiting from the policy changes.)

Quadrant 2:
Measuring Quality of Effort ("How well did we do it?")

PROCESS MEASURES:

  • Percent of Baby Friendly policy promotion materials that are evidence-based and aligned with current guidelines. (Assesses the quality and validity of policy promotion content.)
  • Percent of hospitals receiving intensive technical assistance for Baby Friendly policy implementation. (Measures the level of support provided to facilitate successful adoption.)
  • Percent of hospital Baby Friendly policy efforts that include patient engagement and feedback. (Tracks the incorporation of patient voice and experience in policy decisions.)

OUTCOME MEASURES:

  • Percent of hospitals achieving Baby Friendly designation within one year of policy implementation. (Assesses the efficiency and timeliness of the certification process.)
  • Percent of hospital staff who consistently adhere to Baby Friendly clinical practices post-policy adoption. (Measures the fidelity and sustainment of practice changes.)
  • Percent of mothers who report positive breastfeeding experiences at Baby Friendly policy hospitals. (Captures the impact of policies on patient perceptions of care quality.)

Quadrant 3:
Measuring Quantity of Effect ("Is anyone better off?")

PROCESS MEASURES:

  • Number of state/local health coalitions collaborating to promote Baby Friendly hospital policies. (Assesses the level of collective action and partnership around the initiative.)
  • Number of hospitals that integrate Baby Friendly policies into standard operating procedures and EHRs. (Measures systemization and hardwiring of practice changes.)
  • Number of hospital leadership teams that publicly commit to Baby Friendly policy implementation. (Tracks leadership buy-in and accountability for the initiative.)

OUTCOME MEASURES:

  • Number of mothers and infants who have early skin-to-skin contact at Baby Friendly policy hospitals. (Measures a key practice outcome associated with Baby Friendly care.)
  • Number of hospitals reporting cost savings or improved patient outcomes after Baby Friendly implementation. (Assesses broader health care quality and value impacts of the policies.)
  • Number of Baby Friendly policy hospitals that become regional leaders/mentors for the initiative. (Captures the spread and scale-up of best practices across hospital systems.)

Quadrant 4:
Measuring Quality of Effect ("How are they better off?")

PROCESS MEASURES:

  • - Percent of Baby Friendly policy promotion efforts tailored to hospitals serving high-disparity populations. (Assesses strategic focus on reducing breastfeeding inequities.)
  • - Percent of Baby Friendly policy hospitals that provide culturally and linguistically appropriate care. (Measures equitable implementation of patient-centered practices.)
  • - Percent of hospital Baby Friendly policy teams that include diverse staff representation. (Tracks inclusivity and power-sharing in the policy implementation process.)

OUTCOME MEASURES:

  • - Percent increase in breastfeeding initiation among underserved populations at Baby Friendly policy hospitals. (Measures the policies' impact on equity in breastfeeding outcomes.)
  • - Percent reduction in rehospitalizations for breastfeeding-related issues at Baby Friendly policy hospitals. (Captures a key outcome related to safety and appropriate discharge care.)
  • - Percent of all births in the state/jurisdiction occurring at Baby Friendly designated hospitals. (Tracks the reach and saturation of Baby Friendly practices at the population level.)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

References

1 Strauch, J., Rohrer, J. E., & Refaat, A. (2016). Increased hospital documentation requirements may not increase breastfeeding among first‐time mothers. Journal of evaluation in clinical practice, 22(2), 194-199.

2 Marinelli, A., Del Prete, V., Finale, E., Guala, A., Pelullo, C. P., & Attena, F. (2019). Breastfeeding with and without the WHO/UNICEF baby-friendly hospital initiative: A cross-sectional survey. Medicine, 98(44).

3 Jung, S., Nobari, T. Z., & Whaley, S. E. (2019). Breastfeeding outcomes among WIC-participating infants and their relationships to baby-friendly hospital practices. Breastfeeding Medicine, 14(6), 424-431.

4 Nobari, T. Z., Jiang, L., Wang, M. C., & Whaley, S. E. (2017). Baby-friendly hospital initiative and breastfeeding among WIC-participating infants in Los Angeles County. Journal of Human Lactation, 33(4), 677-683.

5 Spaeth, A., Zemp, E., Merten, S., & Dratva, J. (2018). Baby‐Friendly Hospital designation has a sustained impact on continued breastfeeding. Maternal & child nutrition, 14(1), e12497.

6 Kahin, S. A., McGurk, M., Hansen-Smith, H., West, M., Li, R., & Melcher, C. L. (2017). Key program findings and insights from the baby-friendly Hawaii project. Journal of Human Lactation, 33(2), 409-414.

7 Ducharme-Smith, K., Gross, S. M., Resnik, A., Rosenblum, N., Dillaway, C., Orta Aleman, D., ... & Caulfield, L. E. (2021). Exposure to Baby-Friendly Hospital Practices and breastfeeding outcomes of WIC participants in Maryland. Journal of Human Lactation, 0890334421993771.

8 Liberty, A. L., Wouk, K., Chetwynd, E., & Ringel-Kulka, T. (2019). A geospatial analysis of the impact of the baby-friendly hospital initiative on breastfeeding initiation in North Carolina. Journal of Human Lactation, 35(1), 114-126.

9 Crenshaw, J. T., & Budin, W. D. (2020). Hospital Care Practices Associated With Exclusive Breastfeeding 3 and 6 Months After Discharge: A Multisite Study. The Journal of Perinatal Education.

10 Kivlighan, K. T., Murray‐Krezan, C., Schwartz, T., Shuster, G., & Cox, K. (2020). Improved breastfeeding duration with Baby Friendly Hospital Initiative implementation in a diverse and underserved population. Birth, 47(1), 135-143.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.