341 - Disturbing Trends in US Baby-Friendly designation: Can the Initiative Survive in the US?

Publication Number: 3328.341

Laura Burnham, The Center for Health Equity, Education, & Research, Boston, MA, United States; Olivia Choi, Center for Health Equity, Education, & Research at Boston Medical Center, Hopkinton, MA, United States; Nathan C.. Nickel, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada; Mariah Banks, Center for Health Equity, Education, & Research at Boston Medical Center, Boston, MA, United States; Anne Merewood, Boston University School of Medicine, Boston, MA, United States

Background: UNICEF and the WHO launched the Baby-Friendly Hospital Initiative (BFHI) in 1991, and the first US hospital was designated in 1996. To gain designation, US sites must comply with the Ten Steps to Successful Breastfeeding, and pass an onsite assessment with Baby-Friendly USA (BFUSA), the non-profit overseeing US designation.

The team at the Center for Health Equity, Education, and Research (CHEER) at Boston Medical Center has worked programmatically on the BFHI since 1998. In recent years, we became concerned about a perceived decrease in the number of designated US Baby-Friendly hospitals.

Objective: The goal of the current project was to assess designation trends in US Baby-Friendly hospitals from 1996-2025.

Design/Methods: Using the Way Back Machine, a digital archive of the World Wide Web, we reviewed captured screenshots of the BFUSA website, which lists designated sites, for each year since the US initiative began. We tested for time trends in hospital designation rates using generalized linear models, and used time-to-event models to identify significant predictors of hospitals not pursuing redesignation.

Results: The highest volume of new Baby-Friendly designations was in 2018, when 107 new hospitals were designated. The total number of designated hospitals peaked in 2019 at 623. Numbers since have trended significantly downwards. By the end of 2024, the total number of designated hospitals was 560, just 20 of which were newly designated. Fifty-five hospitals, 9% of all sites from 2023, were removed from the website in 2024, indicating that they did not redesignate. In 2020, for the first time ever in the US, the number of sites not redesignating exceeded the number of newly designated sites. Significant factors related to the decline were the COVID years; being part of a large hospital/health system, and numbers of sites not redesignating (all p= <.05).

Conclusion(s): This is an alarming trend, especially considering that many large health systems are not redesignating. Other nations with previously acclaimed programs have suffered similar declines, often signaling their demise. We recommend urgent changes to the US initiative, to ensure it continues for the benefit of maternal child health.

Cumulative BFUSA Designation Trends (1996-2024)


BFUSA Designation Trends by Year (1996-2024)