The effect of Baby-Friendly Hospital Initiative implementation, accreditation and certification on breastfeeding outcomes of pregnant women in Hong Kong

Breast
milk is the best source of nutrition for infants. However, numerous barriers prevent women from
breastfeeding for the optimal duration recommended by the World Health
Organization and the United Nations Children’s Fund. Overwhelming evidence in
the literature shows a number of benefits of breastfeeding for women and
children. Many interventions and policies have been implemented to improve
breastfeeding rates. One of these is the
Baby-Friendly Hospital Initiative (BFHI) launched in 1991 to promote
breastfeeding through hospital policy. The BFHI is a group of ten steps applied
at a maternal health centre that affects hospital practices. Many studies have reported that BFHI results
in the improvement in breastfeeding.
However, there have been inconsistent results and pre-post studies on
the BFHI are limited. No study has
compared the effects of the different stages of the BFHI designation process on
breastfeeding. Therefore, the objective of this study is to examine the effects
of BFHI implementation, certification, and accreditation on breastfeeding
duration and exclusivity at four geographically-distributed public postnatal
wards in Hong Kong.

This
was a multicentre repeated prospective cohort that took place in Hong
Kong. A total of 2369 mother-infant
dyads were recruited in this study. The two cohorts in this study were
investigated at two different times: before (pre-BFHI) and after implementation
of the BFHI (post-BFHI). Recruitment for pre-BFHI took place from 2011-2012
(n=1240) and post-BFHI took place from 2017-2018 (n=1129). Participants were
followed up through telephone interviews at 1, 3, and 6 months after birth or
until breastfeeding had stopped. Several statistical methods such as the
chi-square test, Cox proportional hazards regression and propensity score
weighting were used throughout the thesis.

Improvements
in the duration and exclusivity of breastfeeding were observed with BFHI
implementation. After adjusting for confounders, participants in the post-BFHI
cohort had 56% (aHR= 0.44; 95% CI: 0.38-0.49) and 56% (aHR= 0.44; 95% CI:
0.40-0.49) lower risks of discontinuing any and exclusive breastfeeding,
respectively. Becoming a Baby-Friendly
Hospital (accreditation) was associated with a 58% (aHR= 0.42; 95% CI:
0.34-0.52) lower risk of discontinuing breastfeeding compared with not
implementing the BFHI. The early stage in BFHI enrolment to begin the
“Certificate of Commencement” was associated with a 61% (aHR= 0.39; 95% CI: 0.32-0.48)
lower risk of discontinuing breastfeeding compared with not implementing the
BFHI. Similarly, accreditation was associated with a 62% (aHR= 0.38; 95% CI:
0.32-0.45) lower risk of discontinuing exclusive breastfeeding compared with
not implementing the BFHI. Certification was associated with a 64% (aHR= 0.36;
95% CI: 0.29-0.44) lower risk of discontinuing exclusive breastfeeding compared
with not implementing the BFHI.

Breastfeeding
duration and exclusivity showed improvement after BFHI was implemented
regardless the level of designation achieved. The results of this thesis
support the implementation of BFHI steps, even in the absence of designation is
important and recommend that just implementing the BFHI stepscan
improvebreastfeeding outcomes.

母乳乃婴幼儿最佳之营养来源。然而，众多障碍阻碍女性能够按照世界卫生组织及联合国儿童基金会所推荐的最优哺乳时长进行哺乳。文献中不乏证实哺乳对妇女及儿童诸多益处的证据。众多干预措施及政策已被实施以提高哺乳率。其中之一便是1991年启动的‘婴儿友好医院倡议’（BFHI），旨在通过医院政策推广哺乳。BFHI包括十项步骤，应用于母婴健康中心，影响医院实践。众多研究已报告BFHI能够改善哺乳状况。然而，BFHI的研究结果存在不一致，且BFHI的前后对比研究有限。尚无研究比较BFHI不同阶段认证过程对哺乳的影响。因此，本研究旨在探讨在香港四个地理分布的公立产后病房中，BFHI的实施、认证及批准对哺乳时长及纯哺乳的影响。

本研究为香港的多中心重复前瞻性队列研究。共有2369对母婴参与本研究。研究中的两个队列分别在BFHI实施前后进行调研：BFHI实施前（2011-2012年，n=1240）和BFHI实施后（2017-2018年，n=1129）。参与者自出生后1个月、3个月和6个月通过电话访谈进行追踪，直至哺乳停止。本文使用了诸如卡方检验、Cox比例风险回归及倾向得分加权等多种统计方法。

BFHI实施后观察到哺乳时长及纯哺乳率的改善。在调整混杂因素后，BFHI实施后的队列中，参与者中断任何哺乳及纯哺乳的风险分别降低了56%（aHR=0.44；95% CI: 0.38-0.49）和56%（aHR=0.44；95% CI: 0.40-0.49）。成为婴儿友好医院（认证）与未实施BFHI相比，中断哺乳的风险降低了58%（aHR=0.42；95% CI: 0.34-0.52）。BFHI注册早期阶段开始“启动证书”的进程与未实施BFHI相比，中断哺乳的风险降低了61%（aHR=0.39；95% CI: 0.32-0.48）。同样，认证与未实施BFHI相比，中断纯哺乳的风险降低了62%（aHR=0.38；95% CI: 0.32-0.45）。认证与未实施BFHI相比，中断纯哺乳的风险降低了64%（aHR=0.36；95% CI: 0.29-0.44）。

无论达到何种认证级别，BFHI实施后均观察到哺乳时长及纯哺乳率的提升。本文的研究结果支持实施BFHI步骤，即使在未获得认证的情况下，这也具有重要意义，并建议仅实施BFHI步骤即可改善哺乳结果。