There were 322 respondents to the survey, 236 of whom completed the majority of the survey. The data within all survey responses was used, with details of the number providing data for each question provided.

SurveyCharacteristics of respondents

The characteristics of the respondents and the type of services they represented are provided in Table 2. Survey respondents were from 16 different countries with the majority from England (60.5%) or Australia (22.2%). A wide variety of professional roles were represented by respondents to the survey, including providers from a diverse range of services, academics, commissioners and a maternity user representative. The majority of respondents worked in services with level 3 or gold BFI accreditation.

Table 2 Characteristics of respondents and their services representBFI impact

When specifically asked which breastfeeding outcomes respondents considered to be most improved with the BFI, almost 90% of respondent felt breastfeeding initiation was improved (178/198) and 80% felt breastfeeding duration was improved (160/198). More than 70% of respondents said that infant health outcomes (145/198) and breastfeeding exclusivity (139/198) were improved. Additionally, more than 60% of respondents stated that maternal health outcomes (129/198) and mental health were improved (119/198).

BFI elements

Participants who were hospital based were asked to rank the BFHI 10 steps in the order they considered important for achieving improved breastfeeding outcomes. Participants who worked in community-based services were asked to rank the Baby Friendly Community Initiative (BFCI) 7 points in the order they considered important for achieving improved breastfeeding outcomes. Participants who worked in a service that was both hospital and community based were asked to rank both the BFHI 10 steps and the BFCI 7 points. Participants whose service was not classified as hospital or community based were asked to rank the BFHI 10 steps. Participants were informed within the question that they could give equal rankings to the different steps/ points.

For the 12 elements contained in the 10 BFHI steps the percentage of respondents ranking each element as 1 or 2 (the most important, or the second most important) are given in Fig. 1. Ensuring that staff have the knowledge, competence and skills to support breastfeeding and facilitate immediate and uninterrupted skin-to-skin contact and initiation of breastfeeding as soon as possible after the birth were ranked as the most or second most important elements by the largest number of participants. Establishing ongoing data monitoring and data management systems was ranked as the most important or second most important by the fewest number of participants, followed by coordinating discharge so parents have timely access to ongoing support. Despite being told explicitly in the question that they could rank the elements of equal importance, only 13 respondents (10.1%) did so.

Fig. 1

Percentage of respondents ranking each element as 1 or 2 (the most important, or the second most important) for each element of the BFHI 10 steps (n = 129)

The percentage of respondents ranking each element as 1 or 2 (the most important or the second most important) within the BFCI points is given in Fig. 2. Training all staff in the care of mothers and their babies with the skills necessary to implement their breastfeeding policy was ranked as first or second most important by the largest number of respondents. Despite being told explicitly in the question that they could rank the community points of equal importance, only 19 respondents (16.8%) did so, with two additional respondents stating within their comments that they would have liked to do so. Of these 21 respondents, 18 were from the UK.

Fig. 2

Percentage of respondents ranking each element as 1 or 2 (the most important, or the second most important) for each of the BFCI 7 points (n = 113)

Interview resultsCharacteristics of the respondents

In total, 15 interviews were conducted with professionals. All the interviewees were female and were from a diverse range of professions (Table 3). They had been in their current roles for 14 months to 15 years. The services that respondents represented had varying BFI accreditation levels. Interviews with professionals lasted between 29 and 93 min. In addition, two interviews were conducted with maternity service users. One of these maternity service users had one child, and the other had two children. Both had breastfed their children.

Table 3 Characteristics of interview respondents

The responses within the interviews and the open questions within the survey are presented below. Figure 3 provides a visual illustration of the themes.

Fig. 3

Themes identified within the interviews and the additional comments section of the survey

BFI as an agent for changeNeeds to be implemented as a whole

All but two of the interviewees, as well as several survey respondents felt that BFI needed to be implemented as a whole, not in a piecemeal fashion. All of the standards/steps were considered necessary and important. However, it was noted that being equally important did not always equate to equal emphasis.

“You can’t have one part of the cog working fantastically well but then the rest of the machine not working because that doesn’t work. The whole point of having it, all the different standards, is that they all work well together and interconnect so there’s no point in having some working and some not.” Interview 7.

Against the backdrop of all the elements being implemented, particular elements highlighted as important the by interviewees included skin-to-skin contact, professional education, educating women, ongoing support to maintain breastfeeding, women’s experiences and clear organizational policies, so everyone in the organization knows how to effectively support breastfeeding. Some welcomed the additional focus within UK standards on infant bonding and attachment.

“It’s [the focus on responsive parenting] made us realise that there’s a lot more to breastfeeding, it’s all about that loving and caring relationship, it’s also about bonding with your baby as well. So it’s a lot more than food.” Interview 8.

Mixed evidence of the impact

When interviewees were asked about the impact of BFI, many saw it as a driver of organizational change, providing a level of accountability to challenge poor or inconsistent practices. The BFI was also seen to ensure that breastfeeding standards remained a high priority within the organization through the constant cyclical and iterative approach of reaccreditation. However, in contrast, one interviewee felt that the three yearly accreditation processes could lead to bursts of activity rather than sustained change.

“I’m a big believer in BFHI because I have seen what it’s like in hospitals where there is no BFHI, where there is no implementation and the practises are appalling and the things that people get away with are shocking, because there is absolutely no accountability. So at least when you are in a BFHI accredited hospital there is a level of accountability there.” Interview 5.

The training provided to staff during the BFI processes was felt to empower them to support women and engage in conversations in a way that they did not prior to the training. It also provided a safe space for staff to debrief their own stories about breastfeeding, making them self-aware and better able to support women. The yearly staff updates were viewed as essential for staff to have up-to-date knowledge and to drive sustainability. As a result, the BFI was considered to help the provision of consistent messages to women.

“I think there’s something about everybody’s singing from the same hymn sheet, so giving out consistent advice.” Interview 4.

However, there were mixed opinions about the impact of the BFI on breastfeeding outcomes. While many felt the BFI positively impacted upon breastfeeding outcomes within their area, others did not see any corresponding increases in duration, with some also feeling that initial gains in breastfeeding outcomes were not sustained. Uncertainty over the impact of BFI was particularly noted among staff members who were not directly involved in the accreditation process. For others, a lack of impact was attributed to being in areas where the predominant culture was to bottle feed, which would require a long time to challenge.

“Our 10 day rates are over 80% of those women that have chosen to breastfeed. So we’ve seen an increase in that … Initiation is difficult because I know for us we’re changing a culture and it’s hard to change that culture overnight. So it might be years down the line that we start to see a true increase in our initiation.” Interview 6.

While several interviewees considered that becoming BFI accredited showed that the service valued breastfeeding and so would attract the public to the health facility or university, others questioned the visibility of BFI to the public. These concerns about visibility were substantiated within this research as neither of the interviewed maternity users had heard of the BFI, despite both being graduates of health- or nutrition related subjects.

“I am not sure [if BFI accreditation impacts breastfeeding outcomes] … I don’t think lots of staff in various roles and the people using the facilities, I don’t think that many of them are very aware of it … I don’t think many [women] know about it. I never have anybody say to me can you tell me where you’re at in your BFI processes, so nobody, nobody at all does … its not widely discussed at all.” Interview 1.

The benefits and burdens of accreditation

Accreditation itself was seen by some respondents as robust and so worth celebrating when achieved. The audits required as part of BFI accreditation and reaccreditation were seen to provide a clear understanding of the support women felt they were receiving and therefore highlighted changes required to improve the services. This adapted improvement science cycle to constantly improve services was appreciated by some interviewees.

“I think once you’ve achieved your accreditation at whichever level, you know, it’s something to be proud of and to shout from the rooftops.” Interview 7.

“You know where the information is going through or where it isn’t or where mothers feel like, no, no-one told me that, why didn’t anyone tell me that or I couldn’t access this service, so you kind of can see the gaps and then you can work to plug in the gaps … and then you can go back to the staff and do updates and then keep going into, you know, that sort of audit training cycle as you move forward which is actually a really helpful structure to have.” Interview 3.

In contrast, many viewed the process of accreditation as a stressful, onerous, time-intensive task that took staff time and focus away from mothers and babies. Some felt that the tick box nature of undertaking BFI accreditation turned supporting breastfeeding into a chore. Some also reported that there was little room for flexibility, for example if the organization was facing other additional pressures during the time period of accreditation, leading to a call for a simplified process or an award that recognized progress towards achieving the standards. Once achieved however participants were able to look back at the value of accreditation and recognize that many of their worries about the actual evaluation process were unfounded. Implementing the standards within an organization was seen as less onerous than the paperwork surrounding accreditation.

“It does seem it’s just one kind of audit after another throughout the year.” Interview 1

“We need to focus our support on the women and families and not worry about paperwork policy, … but I don’t think we need accreditation as it is a pressure which is not needed by professionals, as it makes supporting breastfeeding a chore and not an enjoyable experience for professional or client.” Survey respondent 219.

The cost of accreditation and implementing the BFI standards was also raised as a burden, however, others viewed it as an incentive to put effort into the accreditation process. Concerns were also raised by one respondent about the business aspects of BFI and that people did not really understand that BFI was a company that currently had a monopoly. There were concerns that a lack of competition within the market would increase accreditation costs.

“It’s up to the hospital to find that money to do it, they complain, they always complain that it costs too much.” Interview 5.

“The cost, that was partly why we abandoned it.” Interview 14.

“I think also that BFI is not the be all and end all of everything breastfeeding. … So on some levels, we need some sort of standards to work against, but it may not be BFI standards. If another organisation were to come along and set up a standards company around infant feeding, because at the moment, BFI have got a monopoly … A long time ago, I worked with a head of midwifery who thought BFI was a money-making scheme … I didn’t believe it at the time, but now, yes, they are about, they are about supporting breastfeeding and supporting infant feeding generally, but I also see it as a way of, it is a business … it’s kind of a social enterprise more than anything.” Interview 13.

The way services are currently funded in the UK added to the burden of BFI accreditation, with public health services being moved between the NHS and local government, including sometimes being tendered out, led to fragmentation of services, and difficulties retaining staff. Current funding structures also meant that the services financing breastfeeding support were not the same services that would see the long-term benefits, for example through decreased child hospitalizations. Staff shortages, particularly of midwives, were noted to reduce the amount of time available to support women to make decisions or overcome challenges around infant feeding, with overstretched staff struggling to provide the high standard of care required for BFI accreditation. Staff shortages also increased the use of agency staff, who had not always received BFI training. Staff resistance was viewed as a hinderance to organizational BFI implementation. Furthermore, frustrations were voiced that BFI accreditation was based on mothers’ recollections, not necessarily what actually took place, as documented in the notes. Some organizations also faced difficulties in gaining consent from women to be contacted for this aspect of the accreditation process.

“It’s really a question of proper funding … we have funding for our Infant Feeding Team. It’s a lot of women working part time and way over their hours to make sure that we offer information and support.” Survey respondent 171.

“The public health team was actually in the NHS and it moved into local government and then commissioning of health visiting services moved into Local Authorities and what’s happened has resulted in quite a lot of fragmentation of services.” Interview 3.

“The barriers are often time, so when it comes to sort of like, you know, unlimited skin-to-skin, there’s still that desire at times because of the throughput of women coming through onto a labour ward to take that baby off and get it weighed, to start, you know, to give the Vitamin K, you know, and probably to start your suturing if you need to suture, there’s always time pressures so I think that’s an issue.” Interview 2.

“I think the barrier to that is that not everybody likes breastfeeding and you know, it is hard to say but you have still got staff that don’t like it … I am aware that not everybody likes, not everybody is as passionate about breastfeeding as what I am.” Interview 8

“It is frustrating that an organisation is accredited based on mother’s recollection. Trusts can provide information to assume the conversations were actioned, but we cannot prove mother’s recollection.” Survey respondent 64.

Committed individuals, with dedicated time to specifically champion BFI, were deemed essential for pushing the BFI accreditation process forward. A committed team including managers, senior staff and stakeholders around the BFI champion was additionally seen as important for ensuring that breastfeeding was prioritized at the system level and for enabling sustained change within the organization. Without a committed team, infant feeding leads could feel that they were fighting a battle on their own. Interagency working was viewed as a good way to coordinate breastfeeding support for women throughout the childbearing journey. Committed local politicians pushing the breastfeeding agenda were noted to have a positive effect on accreditation. The continuity of care midwifery model was also called for, for all women, to maximize conversations around infant feeding.

“The infant feeding lead is fighting a battle alone.” Survey respondent 184.

“I think it needs to be a team effort on behalf of whichever organisation you are working with. It can’t just be one person, in one job to take on a project and move things forward. You need to have buy in from other key people or key, just, the workforce is key. The managers are key and the senior, the hierarchy within an organisation need to recognise if you are going baby friendly, you need to have buy in from all those stakeholders.” Interview 13.

“We’ve got to be looking at what’s our models of care within the hospital system, you know, if we persist with this ridiculous fragmented model of care where women don’t ever get to know the midwife who’s caring for them, there’s no trust, there’s no relationship. All of that relational aspect of BFHI gets lost or doesn’t ever get picked up. So then you know, it does turn into this tick box thing … BFHI needs to be part of the bigger picture, so it needs to be part of all women coming in and having a midwifery model, continuity model of care as their default.” Interview 5.

One part of a jigsaw of interventionsNo single intervention is enough

BFI as a programme was deemed to be one part of a jigsaw of interventions that are required to support breastfeeding, with no single intervention viewed as capable of addressing all of the required aspects to improve breastfeeding outcomes.

“It is more than one part that no, no one programme, no help line, no charity, no BFI can be the answer to it all. And it’s making sure that really the environment across the piece, is supportive of and protective of breastfeeding … breastfeeding success and improvements in rates and experience, is not going to be achieved through any one single intervention.” Interview 10.

“I don’t think any one part of this is going to you know, be the sort of silver bullet and increasing breastfeeding rates, I think it has to be a multipronged approach.” Interview 11.

Stakeholders felt that the current advertising of breastmilk substitutes undermined them as they tried to implement BFI practices. BFI could therefore not be effective on its own without country-level government involvement in implementing laws banning any advertisement or other commercial influences around breastfeeding in line with the WHO International Code of Marketing of Breastmilk Substitutes. Stakeholders also viewed the provision of adequate maternity leave and implementation of employment laws that protect breastfeeding as essential.

“All formula advertising should be banned.” Survey respondent 12.

“Mothers who return back to work, need adequate facilities to express breastmilk at the workplace, supported by legislation.” Survey respondent 138.

Addressing social and health inequities

Some felt that the BFI standards had the capacity to address social and health inequalities that exist within society by allowing health professionals to treat women as individuals. However, other interviewees did not feel that addressing such inequalities was the remit of the BFI. Interviewees particularly noted inequity in access to community support services. Additionally, ethnical diversity was considered to be inadequately addressed, including awareness of different traditional infant feeding practices, ease of accessing support especially group support, difficulties in participating in audits for non-English speakers and information leaflets not aimed at women from ethnic minorities, for example, the presentation of mastitis in darker-skinned women.

“You know it does go back to this you know the effects of inequality, the effects of positivity, you know on someone’s kind of I suppose mental capacity to want to make good choices for themselves and their children and so on, its diminished you know, if you’re living in poverty or in very unequal societies as we are, that’s, it’s a really tough end to crack I suppose.” Interview 11.

Education and cultural change essential

A need for cultural change was identified which required better education about breastfeeding for women, for staff and for society in general.

Cultural change is required

While the BFI programme was seen as effective at instigating organizational changes, it was recognized that it was not part of its remit to address cultural change around infant feeding within society. Further initiatives are required that address the context in which women learn to breastfeed and to enhance the value society places on breastfeeding.

“It [BFI] doesn’t capture the context that women are learning to breastfeed in … I think it’s bigger than just, you know, follow these standards, it’s bigger than that, because there are so many cultural, societal influences on feeding. It’s not just ‘this is what you do and this is how you do it and this is why you should be doing it’, it’s all those other pressures that women experience that get in the way of a positive experience.” Interview 14.

Comprehensive information provision for women

Better information provision for women was viewed as essential for enabling them to make evidence-based decisions and for empowering them to counter any inaccurate advice from professionals. The importance of unbiased information was highlighted; with several respondents wanting the benefits and disadvantages of both breastfeeding and providing breastmilk substitutes to be openly discussed. Providing this information during the antenatal period was seen as a way to build key relationships with the woman for postnatal support and to enable the woman to state her infant feeding aspirations so that staff could effectively support her to achieve them postnatally. Others, however, avoided directly asking women about their intentions to prevent shutting down conversations and to allow for the fact that some women change their mind about breastfeeding once the baby has arrived. Survey respondents, interviewees and maternity service users all called for better antenatal education to provide women with more information about the practicalities of breastfeeding, leading to more realistic expectations. A variety of formats for antenatal education were deemed important due to women having different learning styles. Educational materials from different languages or cultural backgrounds were desired to ensure education for all women.

“Even some training before breastfeeding to show them how they can do it more easily, with some tricks they can do to make it much more easier for them to first start breastfeeding, I think that would be really helpful for women.” Maternity user interview 1

“Key is education and empowerment of women and partners to ask for evidence based best practice.” Survey respondent 116.

“Women have different ways in which they learn. So some women want to read something, some women want to look at something, some women want to listen to something, so I think we also have to be mindful about different peoples learning needs.” Interview 5.

Education for staff

The increasing breadth of the BFI programme within the UK to include BFI accreditation for midwifery and health visiting programmes at the university level was appreciated as it was felt to establish the importance of breastfeeding from the very beginning of training. It was also seen to attract potential students, to enhance students’ skills and to potentially influence student’s long-term employability.

“By putting it in universities you’re putting it at the core where it needs to be so that they leave with those skills and then you can just build on it in maternity and health visiting services.” Interview 3.

However, there were calls for accreditation to be available for additional organizations and staff groups such as children’s hospitals including children’s nurses and pediatricians; general practitioner (GP) practices; accident and emergency staff; dieticians; commissioners; and childcare providers. The commencement of training during healthcare professionals’ undergraduate courses, alongside further ongoing training was viewed as essential. Training delivered by others from the same specialty was believed to have the potential for more of an impact.

“If a baby is not well the first place that a mum goes to is the GP isn’t it and their knowledge isn’t good, they’ve not got, they don’t get training in breastfeeding so the automatic solution is to put it on the bottle. So I think we do need to improve medical staff’s knowledge, definitely.” Interview 6.

Enhancing societal awareness

There was a recognition that more work is needed within society to normalize breastfeeding and to immerse society in positive breastfeeding messages. Ideas for societal education included media or social media campaigns, posters and interviews with high profile TV personalities about breastfeeding. There was also a call to add breastfeeding to the national curriculum from primary school upward.

“Breastfeeding needs to be normalised, it should be seen on TV, in the streets, on posters.” Survey respondent 12.

“It would be great to see standards being discussed in schools from very early, absolutely, and again making it normal so … so school children have that perception that breastfeeding is the way to feed a baby and that it’s normal.” Interview 14.