Review

Andini Pramono
Jane Desborough
Julie Smith

The Ten Steps to Successful Breastfeeding Policy Review

ABSTRACT
In 2018, the World Health Organization (WHO) issued the first revision of the 1989 WHO/UNICEF Ten Steps to Successful
Breastfeeding. While there is evidence of the effectiveness of those Ten Steps in increasing breastfeeding rates, there has
been no published analysis of the key differences between the two versions. We aim to summarise the key changes in each
of the Ten Steps and explore the benefits and cost implications.

We first review the background to recent changes and then compare the evolution of each of the Ten Steps since
1989. Thirdly, we explore the implications of new implementation guidelines in terms of the cost and benefits from
different perspectives.

Revisions are subtle, yet meaningful for implementation. A major change made by WHO is subdividing the Ten Steps
into 1) critical management procedures, and 2) key clinical practices. Lessons have been learned on how the change
has shifted the focus from health care staff to parents and families and shifted the responsibility for some elements of
care from hospitals to the community. Exploring the costs and benefits of the Ten Steps, and who has responsibility for
implementation, may increase understanding of how the Baby-Friendly Hospital Initiative (BFHI) can be implemented to
make it more universal, cost-effective and sustainable. Commitment is needed from policy-makers to integrate the BFHI
into health systems and health financing. Future research will examine this at the country level.

Keywords: breastfeeding, health care, policy, BFHI, Ten Steps

Breastfeeding Review 2019; 27(3), 15–28

INTRODUCTION of these and other developmental deviations have not

Breastfeeding is the normal, and therefore optimal,
standard of infant nutrition. Deviating from that
highly-evolved physiological norm creates immediate
and long-term risks for both infants and mothers. For
example, children who are not breastfed have, among
other things, higher rates of obesity, malocclusion and
asthma, and lower intelligence quotients (Grummer-
Strawn & Rollins, 2015), while a lack of breastfeeding
increases maternal risk of ovarian cancer, breast cancer,
type 2 diabetes and osteoporosis (Victora et al., 2016).
Maternal-child bonding is naturally facilitated by the
hormones and skin-to-skin physical contact necessarily
involved in breastfeeding. Development of reproductive
and brain tissue is measurably different in infants
not breastfed, and higher rates of DNA damage and
chromosomal breaks are recorded, while the outcomes
been adequately researched as yet (Minchin, 2015).
Some studies have described the economic, social and
environmental benefits of breastfeeding (Gartner et
al., 2005), which would more accurately be universally
described as the risks of not breastfeeding, or of formula
feeding. However, breastfeeding rates in many countries
are still low. The overall rate of exclusive breastfeeding
for infants under 6 months of age is 40% (World Health
Organization & UNICEF, 2017). This is little changed from
2010 when it was estimated that, internationally, only
about 35% of infants aged 0–6 months were exclusively
breastfed (World Health Organization, 2010).
Following the Innocenti Declaration of 1991, the
World Health Organisation (WHO) and United Nations
International Children’s Emergency Fund (UNICEF)

Breastfeeding Review • VOLUME 27 • NUMBER 3 • NOVEMBER 2019 15

launched the BFHI to help motivate maternity care
facilities to implement the Ten Steps to Successful
Breastfeeding (World Health Organization, 2018). The
Ten Steps had originated in the 1989 WHO/UNICEF
Joint Statement Protecting, promoting and supporting
breastfeeding: The special role of maternity services.
This drew attention to the critical role of health
services in relation to infant feeding. The 1989 Joint
Statement was designed to ensure that maternity
services provide the best start for every infant and
the necessary education and help for mothers to both
successfully initiate breastfeeding and continue doing
so after hospital discharge.
The policies and practices of maternity facilities
and health professionals remain critical to mothers’
experiences of breastfeeding support and success
(Atchan, Davis, & Foureur, 2013). A positive association
between the BFHI and breastfeeding prevalence has
been found in many studies (Spaeth, Zemp, Merten,
& Dratva, 2018). One Swiss study found that infants
born in baby-friendly hospitals were more likely to
be breastfed for longer than those born in non-baby-
friendly facilities (Merten, Dratva, & Ackermann-
Liebrich, 2005). Another study, in Scotland, showed
that babies born in a hospital with the UK BFHI
standard award were 28% (p < 0.001) more likely to be
exclusively breastfed at 7 days postnatally than those
born in non-BFHI hospitals (Broadfoot, Britten, Tappin,
& MacKenzie, 2005). A large, cluster randomised trial in
the Republic of Belarus showed that infants from sites
receiving experimental intervention of the BFHI model
were seven times more likely to be exclusively breastfed
at 4 months and had significantly reduced risks of
gastrointestinal tract infection and atopic eczema than
control infants (Kramer et al., 2001).
Internationally, impact studies demonstrate that
where the BFHI is well integrated, there is an increase
in rates of breastfeeding initiation and duration. BFHI
is one way to try to ensure the recommended and
crucial practice of exclusive breastfeeding from birth,
with its positive effects on the infant microbiome and
thus ongoing child development. The implementation
of BFHI is applicable in all maternity care settings
and its positive impact is seen in different countries
worldwide (Saadeh, 2012). The global evidence
consistently supports the conclusion that adherence to
the BFHI Ten Steps has a positive impact in short-term,
medium-term and longer-term breastfeeding outcomes
across geographies (Perez-Escamilla, Martinez, &
Segura-Perez, 2016). One study in Hong Kong showed
that after implementing a policy of paying market
price for infant formula in public hospitals, there was
a significant decrease of in-hospital supplementation
of breastfeeding babies, a decrease in the overall rate
of premature breastfeeding cessation, and an increase
in the median duration of breastfeeding, from 8 to
16 Breastfeeding Review • VOLUME 27 • NUMBER 3 • NOVEMBER 2019
12.5 weeks (Tarrant et al., 2015). The overall duration
of breastfeeding was significantly longer after free
supplies of infant formula ended.
Although many countries have taken up the BFHI,
still only approximately 10% of children in the
world are born in BFHI facilities. After a process to
evaluate and reinvigorate the BFHI program, in 2017
the WHO and UNICEF updated the evidence base for
BFHI guidance on the protection, promotion and
support of breastfeeding in maternity care (World
Health Organization, 2017). One report of the BFHI
implementation in Latin America and the Caribbean
mentioned several challenges, such as resistance
to change and lack of ownership by medical staff
(Pan American Health Organization & World Health
Organization, 2016). Many staff, particularly doctors,
lacked the commitment and dedication needed for
BFHI implementation. Furthermore, human resource
issues (eg staff shortages, rotation and difficulties in
finding a time for education that would not interfere
with staff members’ clinical duties) were also cited by
many countries as a challenge (Pan American Health
Organization & World Health Organization, 2016). It is a
poor reflection on the state of global medical education
about postpartum care and infant feeding that re-
education is needed before BFHI implementation can
succeed. There would be little tolerance of a situation
in which adult male patients were routinely harmed
due to staff ignorance, yet this has long been the case
in the care of mothers and infants.
The large number of countries implementing the BFHI
on the one hand, and the low percentage of designated
facilities on the other hand, demonstrates the wide reach
the Initiative has achieved, but also indicates the need
for continued improvement in maternity and newborn
care (World Health Organization & UNICEF, 2018). For as
long as adherence to the Ten Steps is limited to selected
facilities, serious inequities in the quality of health care
for newborns and mothers will persist. These challenges
led to the revision of the Ten Steps. For many facility
managers or health practitioners, the implications for
their work are unknown or unclear.
This study aims to summarise the key changes in each
of the BFHI Ten Steps and explore the benefit and cost
implications for maternity care facilities.
RESULTS
Comparison of the old and new versions of the Ten
Steps
There are several differences between the old and new
versions of the Ten Steps. Table 1 compares the two
versions and their implications. Table 2 shows potential
benefits and costs related to the policy and who might be
most impacted.
The changes are in line with the evidence-based
guidelines on breastfeeding support in maternity care
facilities published in 2017 (World Health Organization,
2017). The Steps are sub-divided into 1) the institutional
procedures necessary to ensure that care is delivered
consistently and ethically (critical management
procedures); and 2) standards for individual care of
mother and infants (key clinical practices).
Changes to the wording of the Ten Steps are relevant
to hospital and midwifery practice. Notably, there is a
stronger focus on ‘enablement’, consistent with a human
rights approach (Kent, 2006). In general, the new Ten
Steps version emphasises the education of all staff and
family, including enabling mothers and families through
increasing their knowledge and skills before birth and in
the short time afterwards that women are in maternity
facilities. However, there is also a strong trend towards
greater medicalisation of post-discharge care and
support which needs to be complemented with stronger
support and government resourcing of mother-to-mother
support groups, resourced peer supporters and drop-in
centres for breastfeeding women. Without a substantial
increase in free post-discharge support for the first 6
months of life at least, improvement in the first few days
of life in hospital can be expected to do little to counter the
pressures causing women to end breastfeeding early. The
revised Ten Steps also stresses the need for monitoring
and sustainability of the program.
DISCUSSION
This essay is a first attempt to analyse the changes to
the Ten Steps and to outline some potential impact of
their implementation on governments, hospitals, family
and society. It may therefore be useful to policy-makers,
hospital administrators and others responsible for
implementing the Ten Steps as policy.
The role of family and interaction with maternity
units
The inclusion of family in Steps 1b, 3 and 10 acknowledges
that the whole family is involved in decisions and actions
related to infant feeding, although obviously the mother
is the principal actor. Thus, this policy encourages
health care providers to communicate the infant feeding
policy to parents, enabling them to make informed
and safe decisions. Step 1, which relates to a facility’s
breastfeeding policy has been modified to include three
components (1a. Comply fully with the International
Code of Marketing of Breastmilk Substitutes and relevant
World Health Assembly resolutions; 1b. Have a written
infant feeding policy that is routinely communicated to
staff and parents; and 1c. Establish ongoing monitoring
and data management systems). This revision explicitly
incorporates full compliance with the Code as an essential
step (World Health Organization & UNICEF, 2018). It
Breastfeeding Review • VOLUME 27 • NUMBER 3 • NOVEMBER 2019 17
may also benefit hospitals’ brand image. As the trend of
breastfeeding is increasing, having a written policy that
supports breastfeeding will be beneficial for hospitals,
in that pregnant women who intend to breastfeed will
choose hospitals that support breastfeeding and will
be more likely to bring their baby for care there in the
future. If the hospital provides the right support so that
breastfeeding is established successfully, patient loyalty
and trust may increase, along with the reputation of a
hospital and its patient numbers. One pre-BFHI study in
Italy reported high maternal satisfaction with rooming-in
(Cuttini et al., 1995). In that same study, though, mothers
also reported difficulties related to resting, managing
their babies and interpretation of crying cues, all issues
BFHI implementation needs to address.
Families and infant feeding ‘choices’
The term ‘infant feeding’ used in the new version implies
that hospitals should make a clear policy about all aspects
of infant feeding. This includes the conditions when an
infant formula is safe enough and the best option for the
family although, as was stated in the UK Healthy Child
Programme created under the auspices of the Royal
College of Paediatrics and Child Health (RCPCH), ‘For
infants, formula will always be an inferior choice to breast
milk’ (Renfrew, McCormick, Wade, Quinn, & Dowswell,
2012). WHO has released the Acceptable Medical Reasons
for Use of Breastmilk Substitutes as a guide for health care
professionals (World Health Organization & UNICEF,
2009).
Maternal breastfeeding or breastmilk is a necessity
for normal development of the infant microbiome
(which helps program subsequent infant development).
However, sometimes conditions beyond the family’s
control make the use of breastmilk substitutes from
birth unavoidable. There will always be a tiny minority
of women who cannot breastfeed and others who do not
provide enough milk. In the absence of milk banking,
these families will need to use infant formulas. That being
the case, it is important that all carers of such infants
are individually educated about how to choose, store,
make up and feed such unsterile substitutes, as safely
as humanly possible. Above all, such families need to be
connected to support networks on discharge, as theirs
are the infants at greatest risk of sickness and death. This
also will entail new costs for hospitals, as they cannot rely
on commercially available literature, and staff education
in this area has been lacking.
However, the very fact of a health care facility offering
parents a ‘choice’ between the physiological norm and an
artificial substitute has the capacity to undermine efforts
to protect, promote and support breastfeeding. For many
decades hospitals have served as unwitting marketing
agencies for formula because parents assume that ‘they
wouldn’t have it there and give it to babies if it wasn’t
so close to breastmilk as makes no real difference.’ This
 Table 1. Comparison between the 1989 and the 2018 Ten Steps.
18
Ten Steps (1989)
Have a written breastfeeding policy
that is routinely communicated to all
healthcare staff
Train all healthcare staff in skills
necessary to implement this policy
Inform all pregnant women about
the benefits and management of
breastfeeding
Help mothers initiate breastfeeding
within one half-hour of birth
Show mothers how to breastfeed and
maintain lactation, even if they should
be separated from their infants
Breastfeeding Review • VOLUME 27 • NUMBER 3 • NOVEMBER 2019
Ten Steps (2018)
1a. Comply fully with the International Code
of Marketing of Breastmilk Substitutes and
relevant World Health Assembly resolutions.
1b. Have a written infant feeding policy
that is routinely communicated to staff and
parents.
1c. Establish ongoing monitoring and data
management systems.
Ensure that staff has sufficient knowledge,
competence and skills to support
breastfeeding.
Discuss the importance and management
of breastfeeding with pregnant women and
their families.
Facilitate immediate and uninterrupted
skin-to-skin contact and support mothers
to initiate breastfeeding as soon as possible
after birth.
Support mothers to initiate and maintain
breastfeeding and manage common
difficulties.
Differences/comments
Hospitals are encouraged to read and comply with the Code and a way to measure
compliance is included (1c). Nevertheless, compliance with this can differ between
jurisdictions.
The new version includes parents as a target of communication of the policy.
The old version used the term ‘breastfeeding policy’, while the new one uses term
‘infant feeding policy’.
Hospitals are encouraged to develop system-level processes to monitor and evaluate
simultaneously. It is a non-stop process.
The word ‘train’ implies that hospitals only provide training but are not responsible for
practice. The newest version also includes knowledge and competence. It also implies
that hospitals should also measure the competence and skills of staff in supporting
breastfeeding.
The old version used the word ‘inform’ and it implies one-way communication, while
the new version uses ‘discuss’, implying two-way communication.
The old version mentioned ‘all pregnant women’, while the new version mentions ‘…
and their families’, involving the whole family.
The old version used the word ‘help’ while the new version uses the word ‘facilitate’,
which means hospitals should not only help physically but also assist and provide
support required to initiate breastfeeding. The new version requires ‘immediate’ ‘skin-
to skin contact’ which means ‘skin contact’ is the priority, followed by breastfeeding.
The old version used the term ‘one half-hour of birth’, creating a specific time frame
for this intervention. However, the new version uses the terms ‘immediate and
uninterrupted’ and ‘as soon as possible’, which makes it clearer that this is a priority.
There is no stress on the necessity and immediacy of suckling rather than skin
contact; feeding should occur when the infant expresses a wish to suckle during that
uninterrupted phase of skin-to-skin contact.
The old version used the term ‘show’ which implies the midwives should practice or
perform the breastfeeding process with baby-doll and/or breast model, while the new
version uses the term ‘support’. This implies hospital staff should provide all possible
support, including counselling language and positive gesture.
The old version referred to mother-infant separation, while the new one refers to
common difficulties. This implies not only separation, but other challenges, such as,
nipple trauma and perceptions of low supply.
 Table 1. Comparison between the 1989 and the 2018 Ten Steps (continued).
Ten Steps (1989)
Give newborn infants no food or
drink other than breastmilk, unless
medically indicated
Practise rooming-in – that is allow
mothers and infants to remain together
24 hours a day
Encourage breastfeeding on demand
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Give no artificial teats or pacifiers
(also called dummies or soothers) to
breastfeeding infants
Foster the establishment of
breastfeeding support groups and
refer mothers to them on discharge
from the hospital or clinic
19
Ten Steps (2018)
Do not provide breastfed newborns any
food or fluids other than breastmilk, unless
medically indicated.
Enable mothers and their infants to remain
together and to practise rooming-in 24
hours a day.
Support mothers to recognise and respond
to their infants’ cues for feeding.
Counsel mothers on the use and risks of
feeding bottles, teats and pacifiers.
Coordinate discharge so that parents and
their infants have timely access to ongoing
support and care.
Differences/comments
The old phrase ‘give newborn infants’ could be interpreted as allowing the hospital
to provide other food or fluid, just not give it directly to breastfed babies. The new
version uses the word ‘provide’, implying that hospitals should not provide such foods
in any way, including to the mother or family members so that they can give it to the
infant. This prohibits the practice of giving free supplies of formula at discharge.
Although not WHO’s intention, this might also be read as saying it’s fine to give formula
to not-already-being-breastfed infants, and by singling out ‘breastfed newborns’ no
longer presumes breastfeeding is the universal norm, but just one group of newborns.
It implies that there are formula-fed newborns in every hospital. (Although the Ten
Steps are in fact doing nothing about safer bottle-feeding techniques and strategies.).
The word ‘enable’ means to ‘give (someone) the authority or means to do something;
make it possible for’ rather than just ‘practising’.
The new version prioritises the staff’s role (pre- and postnatally) to educate and
support mothers to understand their infants’ feeding cues. It is a more practical term
than ‘breastfeeding on demand’, in that it requires staff to empower new parents to
differentiate hunger cues from other needs, as well as to understand that babies need
continuous contact. They also suckle for comfort, and so help promote breastmilk
supply. It might help reduce the perception of low milk supply that is commonly faced
by new mothers.
The old version prohibits hospitals giving artificial teats and pacifiers/dummies to
breastfed babies without explaining the risks and reason behind this, while the new
one refers to counselling mothers, hence enabling them to make informed decisions.
However, it would be unfortunate if this revised Step was read as assuming that
bottles and teats and oral objects are normal and not interventions, since all mothers
are to be counselled about their use.
The establishment of breastfeeding support groups is no longer referred to as the
hospital’s responsibility. Hospitals just need to plan well on mothers’ discharge and
make sure that the parents and infants will have access to appropriate support and
care. This change might be considered as further medicalisation of women’s business,
as the ‘ongoing support and care’ may be only be medical, not mother-to-mother,
sources. And it is mother-to-mother sources that are most effective in maintaining
ongoing lactation.
 Table 2. Cost and benefit of the Ten Steps implementation.
20
Ten Steps (2018)
Critical management procedures
International Code of Marketing of
1a. Comply fully with the
Breastmilk Substitutes and relevant
World Health Assembly resolutions
1b. Have a written infant feeding
policy that is routinely communicated
to staff and parents
1c. Establish ongoing monitoring and
data management systems
Ensure that staff has sufficient
knowledge, competence and skills to
support breastfeeding
Key clinical practices
Discuss the importance and
management of breastfeeding with
pregnant women and their families
Breastfeeding Review • VOLUME 27 • NUMBER 3 • NOVEMBER 2019
Perspective Benefit
Hospital Positive hospitals’ brand image means greater trust
in integrity, better reputation, increasing patient
numbers (Neifert, 2013).
Hospital Indicates that hospital policy must also align with
the International Code of Marketing of Breastmilk
Substitutes, and also strengthens implementation
of the policy through requiring its regular
communication to parents as well as staff.
Hospital Quantitative measure of quality of care resulting from
the BFHI
Better understanding of practices and outcomes.
Hospital Hospital may choose methods that are cost-effective
Greater workplace satisfaction for health care staff
due to increased knowledge and skills.
Hospital Easier to evaluate the understanding of women and
their families through demonstration of effective
breastfeeding practices.
Cost
Printing cost
Loss of marketing benefit from formula milk
manufacturers/distributors
Formula cost unless parents provide formula of their
choice.
Cost for staff education, such as facilities, electricity,
meals, etc.
Cost for parents’ education
Major cost is staff time getting re-educated, deciding what
standards and policies to adopt, etc.
Human resources cost
Equipment cost
Potential to divert resources from providing better quality
care and support for optimal infant feeding practices to
the measurement of outcomes
Education/training cost, such as printing cost, facilities,
etc.
Interfering with staff members’ clinical duties — time
away from clinical care to attend education sessions
(Pan American Health Organization & World Health
Organization, 2016)
Human resources cost
Longer consultation time means lower patient throughput
per hour in the outpatient department
Need bigger rooms and/or more chairs to accommodate
whole family education
 Table 2. Cost and benefit of the Ten Steps implementation (continued).
Ten Steps (2018)
Facilitate immediate and
uninterrupted skin-to-skin contact
and support mothers to initiate
breastfeeding as soon as possible
after birth
Support mothers to initiate and
maintain breastfeeding and manage
common difficulties
Breastfeeding Review • VOLUME 27 • NUMBER 3 • NOVEMBER 2019
Do not provide breastfed newborns
any food or fluids other than breast
milk, unless medically indicated
21
Perspective Benefit Cost
Society Increasing the breastfeeding initiation rates —
Decreasing newborn morbidity and mortality rates
(Brady, 2012).
Hospital Family education on how to help and when to call for In the case of caesarean birth, this could mean the
professional help. midwife is required to spend more time in theatre and
recovery, hence reduced staff availability on the ward
Hospital Maternal satisfaction leading to customer loyalty to More time spent with women to ensure adequate
hospital. education and comfortable breastfeeding, potentially
requiring higher staff: patient ratios
Educating all staff in contact with mothers to recognise
poor positioning or attachment, and early signs of nipple
damage or engorgement
Various breastfeeding tools, such as hospital-grade breast
pump
Time
Mother Mothers empowered and motivated with more Stress trying to learn too much in too short a time,
knowledge and skills to maintain breastfeeding, eg on undermining pride and pleasure in the baby.
discharge to home.
Hospital Less storage space taken up by infant formula and/or Loss of revenue, marketing benefit and discounts from
free sample bags. formula manufacturers/distributors
Need to access donor human milk
Family Better initial milk supply as infant appetite is not Costs of any milk expression and storage materials
sated by other foods
Cost savings for families not purchasing formula and
associated equipment.
Infants Optimised immunity and reduced health care costs in
the future related to other benefits of breastfeeding
(Victora et al., 2016)
Improved IQ and better educational outcomes
(Kramer et al., 2008).
 Table 2. Cost and benefit of the Ten Steps implementation (continued).
22
Ten Steps (2018)
Enable mothers and their infants
to remain together and to practise
rooming-in 24 hours a day.
Support mothers to recognise and
respond to their infants’ cues for
feeding.
Counsel mothers on the use and risks
of feeding bottles, teats and pacifiers
(also called dummies or soothers).
Breastfeeding Review • VOLUME 27 • NUMBER 3 • NOVEMBER 2019
Perspective Benefit
Hospital Decreasing the need for nursery rooms in countries
that still use these for well babies, such as Indonesia.
Mother Increasing the successful rate of breastfeeding
Enhanced bonding of mothers and babies
Partners and other family can provide skin-to-skin
‘kangaroo care’.
Hospital Improving maternal self-efficacy means reduced need
for health care staff assurance.
Mother Mothers are more empowered to provide appropriate
care for their babies through understanding and
responding appropriately to baby’s cues.
Decreasing mother’s engorgement risk and infection
related to mastitis.
Hospital
Mother Increasing the mother’s knowledge and confidence
to make decisions and also to explain to the extended
family about the decisions.
Cost
May require bigger rooms to keep the baby together with
the mother and for the partner to assist
Caring for a newborn baby requires a team to support the
mother. Hospitals need to ensure mothers have suitable
support people in this period
Mothers may be more fatigued, and their supporters need
to be educated and resourced
Increasing nurses’ workload related to education and
support
More skills and knowledge requirements of staff of
‘responsive feeding’ eg in recognising cues and poor
feeding.
Maternal time
Increasing nurses’ workload
Time — parental and midwives
 was the route for western adoption of infant formula as

Government needs to build and support referral systems

the societal norm, a process now well underway in less

maintain peer supporters and groups with well-trained

specialist care (eg lactation consultants, paediatricians,
of both breastfeeding mother-to-mother support and
affluent societies. So, the development or adoption of a

Community needs to lobby government for funds to

policy — ideally a national policy — for those who do not

Reduced interaction with community and poorer

breastfeed is as important as a policy for those who do.
There should be no suggestion in either policy that the

relationships with mother support groups

and experienced counsellors, such as ABA
method adopted is of little consequence, for as industry
once printed on all formula cans, ‘What we feed them
now matters forever.’

Maintain skill and knowledge

Policy development and education
Hospitals are encouraged to build monitoring and data
management systems, which will facilitate measurement
of outcomes during the limited period of care. This, and
provision of human resources, including education, will
family doctors)

add to hospital costs.

Similar to Step 1, Step 2 (Ensure that staff has

Cost

sufficient knowledge, competence and skills to

support breastfeeding) will benefit hospitals who
choose cost-effective methods. Lactation management
education needs to be included in national curricula
establishing support groups has been removed from
the hospital and therefore placed in the hands of the
community from this change. In fact, the burden for

for all medical staff education as pre-service training

No establishment cost for breastfeeding support

(World Health Organization & UNICEF, 2016, 2018).

There is no added benefit for families or the

All those who interact with postpartum mothers need

to be knowledgeable about both natural and substitute
feeding, and specialist support (including but not
limited to lactation consultants) should be available for
Reduce child re-hospitalisation.

more complex problem-solving. One study in Indonesia

reported that specialist support from lactation
consultants was lacking, while at the same time
general medical staff such as physicians, nurses and
midwives had no training in breastfeeding management
Table 2. Cost and benefit of the Ten Steps implementation (continued).

(Flaherman et al., 2018). The lack of basic competence in

most staff and the lack of access to breastfeeding-expert
community.

staff are major barriers to exclusive breastfeeding that

Benefit

groups.

need to be addressed if the new Ten Steps are to be

effectively implemented.

Changes to Step 3 from ‘inform’ to ‘discuss’ (Discuss

Perspective

Government

the importance and management of breastfeeding with

Community

pregnant women and their families) will influence

Hospital

hospitals in several ways. Of course, many hospitals

have been discussing such issues with parents, not
simply providing written information, but using open-
ended interviews and even questionnaires. However,
Coordinate discharge so that parents
and their infants have timely access

where the provision of written information has been

predominant, this change to the policy will have
to ongoing support and care.

benefits to parents and families. On the other hand,

hospitals may need to provide better facilities such as
bigger rooms and/or more chairs if the mother’s family
is more than her partner. Further, more staff will be
Ten Steps (2018)

needed to ‘discuss the importance and management of

breastfeeding with pregnant women and their families,’
as possibly longer consultations during antenatal
visits may lower patient throughput in outpatient
departments. Research on effective strategies to
involve parents in enabling antenatal discussion of

Breastfeeding Review • VOLUME 27 • NUMBER 3 • NOVEMBER 2019 23

infant feeding is needed, as many are focused on the
birth rather than what comes after it. Previous studies
have indicated the benefits of patient enablement,
including improving patients’ self-efficacy, resulting
in better health outcomes and quality of life while
achieving health care goals (Desborough, Banfield,
Phillips, & Mills, 2017).
Initiation of lactation
The change to the term ‘as soon as possible after
birth’ in Step 4 emphasises the need for immediate
and uninterrupted skin-to-skin contact after birth and
support for mothers to facilitate breastfeeding when
the unmedicated infant spontaneously seeks to suckle.
Most routine procedures do not need to be done
immediately after birth and in some hospitals initiation
of breastfeeding takes priority without incident. Skin-
to-skin contact triggers early breastfeeding which is
associated with breastfeeding exclusivity at hospital
discharge and decreased newborn morbidity and
mortality rates (Crenshaw, 2007; Debes, Kohli, Walker,
Edmond, & Mullany, 2013). The mother and baby
should always have knowledgeable support during
early postnatal skin-to-skin and breastfeeding. Ideally
her support person, often the child’s father, has been
educated about potential concerns for mother and
baby.
In the case of caesarean birth, skin-to-skin contact and
early breastfeeding could mean the midwife is required
to spend more time in the operating theatre and recovery
room, potentially reducing staff availability on the ward.
Nowadays partners are encouraged to accompany the
mother in the operating room (Australian Breastfeeding
Association, 2017), and this could be one solution to
ensure monitoring of mother-baby stability during the
skin-to-skin contact process in the recovery room. Some
studies refer to the positive effects of partners’ presence
in the operating theatre, including reducing mothers’
anxiety and cementing the partners’ role in childrearing,
reflecting current occupational positions on patient
autonomy of decision and quality of care (Gutman &
Tabak, 2011). Nonetheless, the safety of this practice
should be prioritised by hospital staff (Baby-Friendly
USA, 2012).
In some countries, the Ten Steps were adapted and
interpreted specifically for its implementation within
the country. For example, in the UK, Step 10 states
to identify sources of national and local support for
breastfeeding and ensure that mothers know how to
access these prior to discharge from hospital (UNICEF
UK, 2014). In Australia, there is another version of
Step 4 (Australian College of Midwives, 2016), which
states to place babies in skin-to-skin contact with their
mothers immediately following birth for at least an
hour and encourage mothers to recognise when their
babies are ready to breastfeed, offering help if needed.
24 Breastfeeding Review • VOLUME 27 • NUMBER 3 • NOVEMBER 2019
This was also used by the US as interpretation of the
original 1989 Ten Steps (Baby-Friendly USA, 2016).
Use of the terms ‘support’ and ‘common difficulties’
in Step 5 (Support mothers to initiate and maintain
breastfeeding and manage common difficulties) means
the hospital staff should do everything possible to
facilitate mothers’ capacity to breastfeed, including
helping them to overcome common challenges mothers
face such as nipple trauma (where staff are ill-educated
about breastfeeding) and perceptions of low supply. The
aim is to empower and motivate parents and families
through the provision of knowledge and skills to maintain
breastfeeding despite the challenge. Hospital costs will
be incurred in relation to providing counselling toolkits,
breastfeeding tools (eg hospital-grade breast pumps)
and time.
When Steps 1–5 are implemented successfully, there is
an increased likelihood of a mother breastfeeding her
child, therefore avoiding costs related to the purchase
of formula and related equipment. This will optimise
the fulfilment of Step 6 (Do not provide breastfed
newborns any food or fluids other than breast milk,
unless medically indicated).
Formula milk companies often provide funds to renovate
or build facilities in hospitals and for health care staff
training, as well as providing free formula and newborn
starter pack gifts (most of which contain either formula
or coupons for formula) for distribution to new mothers.
These free starter packs are an efficient and effective
marketing method by which formula manufacturers
incentivise hospitals to encourage new mothers to
try their company’s formula (Rosenberg, Eastham,
Kasehagen, & Sandoval, 2008). An article mentioned that
formula manufacturers sponsor a variety of activities
targeting parents and parents-to-be, as well as hospital
staff (Tay, 2017). They also underwrite hospital activities
such as the printing of maternity brochures, as well
as corporate dinner-and-dance events. According to
the hospitals contacted, such payments and ‘in kind’
monetary sponsorship by formula milk manufacturers
help reduce the cost of running such activities and defray
the cost of nursing education and training (Tay, 2017).
(The cost is in fact borne by parents who purchase infant
formula, a product with a huge profit margin that allows
for massive marketing costs.)
However, the RCPCH stopped accepting direct
sponsorship from infant formula milk companies (IFMCs)
and suffered no adverse financial effects (Tay, 2017).
Many UK organisations and The Pakistan Paediatric
Association reject all IFMC funding, yet successfully run
affordable large meetings and conferences (Wright &
Waterston, 2006). We have found no studies examining
the financial impact of not accepting sponsorship from
formula companies on hospitals.
For Step 7 (Enable mothers and their infants to remain
together and to practise rooming-in 24 hours a day)
hospitals may benefit from the decrease of nurses’
workload in the nursery (if there is such a room). As all
the healthy infants are rooming-in with their mothers,
nurses will be able to spend more time enabling mothers
and families through education and support increasing
their knowledge, skills and capacity to implement
breastfeeding successfully. Nursing behaviours that
optimise enablement are listening to and watching
patients, trusting patients’ self-knowledge and guiding
and suggesting (Desborough et al., 2017). On the other
hand, hospitals may need to review bedding and space
arrangements. Encouragement of rooming-in needs to
take into consideration the safety of babies, as while
co-sleeping is known to help babies settle and support
breastfeeding, approximately 50% of SIDs babies die
while co-sleeping in unsafe situations (UNICEF, 2018).
After birth, the 2-hour recovery period requires careful
nursing assessment to ensure safety of mother and
baby. Medications given for pain after birth can cause
drowsiness, therefore it can increase the risk of babies
falling to the floor if mothers fall asleep (Simpson,
2015). This can differ in various cultural settings, such
as whether or not it is common to have the partner or
extended family members to accompany the mother and
help care for the baby.
Changes to Step 8 (Support mothers to recognise and
respond to their infants’ cues for feeding) require a
good understanding of babies’ feeding cues by hospital
staff, so as to support mothers to learn about these cues.
Hence this is related to Step 2, ensuring that staff has
sufficient knowledge, competence and skills to support
breastfeeding. The use of the term ‘cues for feeding’
instead of ‘breastfeeding on demand’ implies providing
a broader educational base that includes understanding
cues other than those just related to breastfeeding. This
aims to enhance parenting skills in general, including the
ability to understand when babies are tired, distressed or
hungry and to respond to cues appropriately. Similar to
Step 7, this will enable a mother to fulfil her baby’s needs
at the same time countering perceptions of low supply.
By breastfeeding the baby on demand, mothers will also
benefit by decreasing the risk of engorgement (common
with scheduled feeding). Infants will benefit from less
weight loss in the immediate postpartum period and
increased duration of subsequent breastfeeding, with
lower bilirubin levels during the early neonatal period
(World Health Organization, Division of Child Health
and Development, 1998). At the same time, this will
increase the nurses’ workload related to education and
support and require more skills and staff knowledge of
responsive, efficient and comfortable feeding.
The change to Step 9 (Counsel mothers on the use and
risks of feeding bottles, teats and pacifiers) is the most
controversial with its significant shift from the earlier
Breastfeeding Review • VOLUME 27 • NUMBER 3 • NOVEMBER 2019 25
position of recommending avoidance of these tools
(Aryeetey & Dykes, 2018). It is not to suggest a relaxation
in the emphasis on protection, promotion and support
of breastfeeding, but rather an acceptance and support
to parents not exclusively breastfeeding (Aryeetey &
Dykes, 2018). Counselling mothers on the use and risks
of feeding bottles, teats and pacifiers will increase their
knowledge and confidence to make decisions, as well
as that of the extended family who often take part in
care of the baby. In many countries, the grandmother
is the main member of the extended family who assists
with care of the baby. Grandmothers’ infant feeding
practices influence new mothers’ decisions to initiate
and continue breastfeeding (Grassley & Eschiti, 2009). If
a grandmother has not breastfed, she may offer advice
that reflects her experience with bottle-feeding and
thus undermine her daughter’s confidence and ability
to establish breastfeeding. Other studies have found
that grandmothers’ advice can undermine breastfeeding
(Grassley & Eschiti, 2009).
WHO is well aware that bottles, teats and pacifiers
have more risks than benefits (Sexton & Natale, 2009),
particularly in locations where access to clean water is
difficult. If the health care worker does not counsel on
their use, eventually mothers will find information from
outside, probably from incompetent sources and/or from
companies that violate the WHO Code. Then they would
use the bottle, teat and/or pacifier without knowing
the risk or how to minimise the risk. Inevitably, this is a
necessary step and WHO’s guidance should be publicised
(World Health Organization, 2007).
Changes to Step 10 (Coordinate discharge so that parents
and their infants have timely access to ongoing support
and care) mean that the establishment of breastfeeding
support after discharge is no longer considered by WHO
and UNICEF to be the hospital’s responsibility. This
therefore reduces establishment costs of such groups.
However, this recognises the responsibility of either
government or other organisations for building a referral
system to breastfeeding support groups and lactation
consultants; ideally one that is free of conflict of interest
and in full compliance with the International Code.
Currently there is no Code provision that specifically
prohibits financial relationships between formula
manufacturers and breastfeeding support groups.
However, in Indonesia, formula companies use a social-
media-based marketing approach, which in effect is
commercial implementation of Step 10. They hold writing
competitions for bloggers and provide parenting and/or
health seminars in conjunction with social community
groups such school-based parents groups or kindergarten
and primary school teachers. They also hold a brand
ambassador contest in the community to campaign for
their products. However, bloggers are part of the public,
which allows manufacturers to use popular bloggers’
influence to promote their products (Abrahams, 2012).
An important finding is that community support in Step
10 appears to be key for long-term sustainability of the
short-term breastfeeding gains obtained as a result of
BFHI efforts focusing solely in hospitals (Perez-Escamilla
et al., 2016).
The Ten Steps revision was based on studies that
described the barriers, challenges and success stories of
implementing the policy since it was launched in 12 pilot
countries in February 1992 (World Health Organization
& UNICEF, 2016). Not all benefits were experienced by
all facilities; therefore, the authorities need to establish
incentives for facilities. For example, the Hospital
Readmissions Reduction Program in the United States
financially penalises hospitals if they exceed expected rates
of readmissions within 30 days of discharge (McIlvennan,
Eapen, & Allen, 2015). Perhaps such a policy could be
developed to incentivise hospitals to achieve desired rates
of breastfeeding on discharge. The national breastfeeding
authorities need to commit to sharing the burden of
implementation with other stakeholders, for example
including lactation management in the national curricula
of all medical profession education as pre-service training
(World Health Organization & UNICEF, 2016). They also
need to integrate the policy with other established national
quality assurance systems, such as hospital accreditation,
to maintain sustainability (Saadeh, 2012). Making BFHI
assessment freely available, and accreditation a condition
for licensure as a maternity unit, would seem reasonable
in view of the potential reduction in ongoing disease and
premature infant and maternal deaths.
Strengths and limitations
The strength of this analysis is the systematic approach
we have taken in considering the changes to the Ten
Steps. We were limited in our capacity to study how the
changes may be applied at the individual country level
or in practice in a variety of hospital and institutional
settings. This will be a focus of future research.
CONCLUSION
Comparing the 1989 and 2018 Ten Steps has provided
an opportunity to explore the way that subtle changes to
words and phrasing can shift the focus from health care
staff to parents and families and, at the same time, shift
responsibility for some elements of care from hospitals to
the community. Hence examining the associated costs and
benefits of the Ten Steps, and the associated responsibility
for implementation, helps us to understand the changes
needed for BFHI to be implemented to make it universal,
cost-effective and sustainable. Commitment is needed
from policy-makers to understand how the BFHI can be
applied in different health systems and the implications
for health financing and other established accreditation
systems to ensure the sustainability of the program. Future
research needs to examine in detail how this will occur at
the country level such as in Australia and Indonesia.
26 Breastfeeding Review • VOLUME 27 • NUMBER 3 • NOVEMBER 2019
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AUTHORS
Andini Pramono MPH IBCLC
Department of Health Services Research and Policy
Research School of Population Health
Australian National University
Jane Desborough DAppScNursing GDipMid MPH PhD
Department of Health Services Research and Policy
Research School of Population Health
Australian National University
Julie Smith BEc (Hons)/BA (Asian Studies) PhD
Department of Health Services Research and Policy
Research School of Population Health
Australian National University

CORRESPONDING AUTHOR

Andini Pramono
Health Services Research and Policy Department
Research School of Population Health
Australian National University
63 Eggleston Road
Acton 0200
Canberra Australia
Phone: +61 0406614177
Email: andini.pramono@anu.edu.au

28 Breastfeeding Review • VOLUME 27 • NUMBER 3 • NOVEMBER 2019