The impact of the Baby-Friendly Hospital Initiative on breastfeeding rates at maternity units in France

Abstract

Background: The Baby-Friendly Hospital Initiative (BFHI) is associated with improved breastfeeding outcomes in many high-income countries including the UK and the USA, but its effectiveness has never been evaluated in France. We investigated the impact of the BFHI on breastfeeding rates in French maternity units in 2010, 2016 and 2021 to assess if the BFHI aids to reduce inequalities in breastfeeding.

Methods: We examined breastfeeding in maternity units (exclusive, mixed and any breastfeeding) in mothers of singleton full-term newborns using the 2010 (n = 13 075), 2016 (n = 10 919) and 2021 (n = 10 209) French National Perinatal Surveys. We used mixed-effect hierarchical multinomial regression models adjusting for neonatal, maternal, maternity unit and French administrative department characteristics, and tested certain interactions.

Results: The adjusted rate of exclusive breastfeeding was higher by +5.8 (3.4-8.1) points among mothers delivering in BFHI-accredited maternity units compared with those delivering in non-accredited units. When compared with average-weight newborns, this difference was sharper for infants with low birthweight: +14.9 (10.0-19.9) points when their birthweight was 2500 g. Mixed breastfeeding was lower by -1.7 points (-3.2-0) in BFHI-accredited hospitals, with no notable difference according to the neonatal or maternal characteristics.

Conclusion: Mothers delivering in BFHI-accredited maternity units had higher exclusive breastfeeding rates and lower mixed breastfeeding rates than those delivering in non-accredited maternity units. The positive impact of the BFHI was stronger among low-birthweight neonates, who are less often breastfed, helping reduce the gap for this vulnerable group while favouring mothers with higher education levels.

Keywords: Baby-Friendly Hospital Initiative; Breastfeeding; France; inequalities.

Figure 1.

Number of Baby-Friendly Hospital Initiative (BFHI)-accredited maternity units by French administrative departments in 2010 (A), 2016 (B) and 2021 (C) in metropolitan France. Data source: BFHI France

Figure 2.

Difference in predicted exclusive (only breastmilk), mixed (breastmilk and formula) and any (addition of exclusive and mixed) breastfeeding rates in maternity units between mothers who delivered in a Baby-Friendly Hospital Initiative (BFHI)-accredited maternity unit and those that delivered in non-BFHI-accredited maternity units, or the marginal effect of the BFHI. Any breastfeeding rates are equal to the sum of exclusive and mixed breastfeeding rates. The five nested models cumulatively adjusted for the BFHI and the year (model one), the individual characteristics (Model two), the maternity unit characteristics (Model three), the French administrative department characteristics and random effect (Model four) and interaction terms between the BFHI and some individual characteristics (Model five). Data source: 2010, 2016 and 2021 French Perinatal National Surveys

Figure 3.

Marginal predictions of mixed breastmilk and formula (triangle) and exclusive, only breastmilk (circle) breastfeeding rates in maternity units for the variables included in the final model (Model five). The final model included the Baby-Friendly Hospital Initiative (BFHI), neonatal, maternal, maternity unit and French administrative department characteristics, as well as a spatial random effect at the department level, and interactions terms between the BFHI and the maternal education level and neonatal birthweight. Section (A) shows the predictions against the maternal variables, (B) the newborn variables, (C) the maternity unit variables, (D) the French administrative department variables and (E) the French administrative department-specific random effect for the three highest and lowest values. The vertical lines indicate the mean marginal prediction for each type of breastfeeding. Data source: 2010, 2016 and 2021 French Perinatal National Surveys

Figure 4.

Marginal predictions of mixed breastmilk and formula (triangle) and exclusive, only breastmilk (circle) breastfeeding rates in maternity units for the variables in interaction with the Baby-Friendly Hospital Initiative (BFHI) in the final model (Model 5). The ‘Accredited’ and ‘Non-accredited’ sections present the marginal predictions for mothers who delivered in a BFHI-accredited and non-accredited maternity unit, respectively. The section ‘Difference’ presents the marginal effects, that is, the differences in predicted breastfeeding initiation rates between accredited and non-accredited maternity units. The vertical lines indicate the mean marginal prediction for each type of breastfeeding. The horizontal lines across the triangles or circles represent the 90% confidence interval. The model included the BFHI variable, neonatal, maternal, maternity unit and French administrative department characteristics, as well as a spatial random effect at the French administrative department level, and interactions terms between the BFHI and the maternal education level and neonatal birthweight. Data source: 2010, 2016 and 2021 French Perinatal National Surveys