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. 2019 Jun 11;15(4):e12845. doi: 10.1111/mcn.12845

A comparison of exclusive breastfeeding in Belgian maternity facilities with and without Baby‐friendly Hospital status

Emmanuelle Robert 1,✉, Isabelle Michaud‐Létourneau 2, Michèle Dramaix‐Wilmet 1, Béatrice Swennen 3, Roland Devlieger 4,5,6
PMCID: PMC6859970  PMID: 31106522

Abstract

A retrospective cross‐sectional study was carried out in Wallonia (the southern region of Belgium) in which a 20‐question breastfeeding (BF) module was included in an immunization survey. The purpose of this paper is to compare exclusive breastfeeding (EBF) prevalences and BF practices for mothers giving birth in Baby‐friendly Hospital Initiative (BFHI) and non‐BFHI maternity facilities. A total of 557 mothers responded to BF questions when their child was 18–24 months old; 26.7% of them delivered in a BFHI maternity facility. At discharge, a larger proportion of children were exclusively breastfed if they were born in a BFHI maternity facility (76.5% vs. 65.8%, p = .02). The median duration of EBF (15.0 vs. 12.9 weeks, p = .3), and the proportion of children exclusively breastfed at 5 months (16.8% vs 15.8%, p = 1.0) were similar in both groups. Few mothers knew that EBF was recommended for the first 6 months of life (28.6% in BFHI vs 23.1% in non‐BFHI, p = .2). For most groups of the population examined, the rates of BF tended to be higher in BFHI facilities, but many differences were not significant. More specifically, BFHI seemed to boost BF practices among mothers more likely to breastfeed, but the Initiative did not seem to trigger enhanced BF practices in mothers traditionally less likely to breastfeed (except for indifferent/negative partner's attitude and mothers of Belgian origin). Influencing the BF practices of mothers less likely to breastfeed requires a special attention with complementary actions in maternity facilities as well as in community services.

Keywords: Baby‐Friendly Hospital Initiative, breastfeeding duration, breastfeeding initiation, breastfeeding promotion, exclusive breastfeeding, public health

Key messages.

  • Immunization coverage surveys can be used effectively and at limited cost to monitor breastfeeding (BF).

  • In Wallonia, the southern region of Belgium, although BF practices are slightly better in mothers who gave birth in BFHI maternity facilities, the BFHI appears insufficient to significantly influence BF practices, especially in populations less likely to BF.

  • Requiring a minimum EBF rate for BFHI labelling in a region with relatively low BF rates could penalize maternity facilities with the lowest EBF rates and that would most benefit from an effective BF supportive environment.

1. INTRODUCTION

The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend that infants be exclusively breastfed for the first 6 months of life to achieve optimal growth, development, and health and that they should receive nutritionally adequate complementary foods thereafter, with continued breastfeeding (BF) for up to 2 years of life or beyond (World Health Organization, 2003). BF is associated with reduction of childhood infections, malnutrition, infant mortality, obesity, and type 2 diabetes (Victora et al., 2016). A dose–response relationship is well recognized (Eidelman, 2012). BF is also associated with maternal risk reduction in breast and ovarian cancers (Rollins et al., 2016). To increase BF initiation, duration, and exclusivity, the Baby‐friendly Hospital Initiative (BFHI), a WHO/UNICEF global programme, has been launched in 1991 (Saadeh, 2012). The accreditation requires compliance with each of the 10 steps to successful BF, which include compliance with the International Code of Marketing of Breast‐milk Substitutes (World Health Organization & UNICEF, 2018). It also requires reaching a 75% EBF rate at the discharge from the maternity ward (World Health Organization & UNICEF, 2009). As recommended, most countries take this last condition as mandatory to obtain BFHI certification, including Belgium. Globally, more than 27.5% of maternity facilities had been certified in 2010–2011 (8.5% of those in high‐income countries and 31% in low‐ and middle‐income countries; Labbok, 2012). In 2017, 10% of infants in the world were born in a facility designated as “Baby‐friendly” at that time (WHO, 2018). In Belgium, the implementation of the BFHI began in 2005. By 2017, 27% of maternity facilities held the BFHI label, accounting for more than 32% of all births nationally. However, there is still no BF systematic monitoring of the situation of BF practices. There is thus a lack of information on BF prevalences and duration in the country or on their association with the BFHI status of maternity facilities. A recent Lancet paper underlined the absence of BF data for Belgium (Victora et al., 2016). The present study seeks to begin to address this gap by providing insights regarding BF prevalences and practices in the context of the BFHI programme in one of three regions of Belgium, based on population data. The purpose of this paper is to compare prevalences and other information on BF practices for mothers giving birth in BFHI and non‐BFHI maternity facilities.

2. METHODS

2.1. Population and sampling

A module of 20 questions on BF practices was introduced in an immunization survey in Wallonia (the southern region of Belgium) in 2015. An Expanded program of Immunization‐based two‐stage cluster sample (World Health Organization, 2015) was performed. A minimum of nine children in each cluster was required because the minimum required for the study was 495 children based on the coverage rate of 89.6% of meningococcal C vaccine from a previous study (Robert, Dramaix, & Swennen, 2014). The nonrespondents rate of the previous study was added to the minimum children to reach. A list of the number of children resident in each municipality from Wallonia was obtained from the Directorate‐General Statistics and Economics Information. From this list, 55 clusters were randomly selected with a probability proportional to size (several clusters could be drawn in the largest municipalities). A total of 51 municipalities were selected. A list of children born between May 31 and November 30, 2013 was obtained from each municipality. Thirteen children in each cluster were randomly selected from the list of each municipality. The family of each child selected received a letter announcing that an interviewer would visit them to conduct a survey on infancy. Families that could not be contacted after three attempts (at different days and times) or those with serious language difficulties were excluded and substituted with a replacement, even if they had agreed to participate. The database was registered with the commission for the protection of the privacy in Belgium.

2.2. Variables and definitions

Trained interviewers obtained BF data retrospectively from mothers or parental couples who participated in the immunization survey. EBF was defined according to the WHO and means that an infant receives only breast milk from his or her mother or a wet nurse, or expressed breast milk, and no other liquids or solids, not even water, with the exception of oral rehydration solution, drops, or syrups consisting of vitamins, mineral supplements, or medicines. The questions on BF were grouped into four categories: (a) type of BF (exclusive, partial, and none) at birth and at discharge from the maternity facility; (b) age of the child when EBF and any BF were stopped; (c) factors potentially associated with EBF (birth in a BFHI facility, mode of delivery, partner's attitude towards BF, etc.); and (d) BF information and support received from health professionals during the maternity stay (benefits of BF, EBF‐recommended duration, existence of contradictory messages, etc.). All categorical variables were dichotomized apart from the BF experience, which was broken down into three categories: (a) multiparous with prior BF experience; (b) multiparous without prior BF experience; (c) and primiparous. The parents' level of education was broken down into four categories: (a) ≤3‐year secondary school; (b) completed secondary school; (c) higher than secondary level but nonuniversity diploma; and (d) university diploma. Family income was broken down into two categories: (a) no labour income, referring to children born in families where neither parent had a paid job, irrespective of whether or not they received a substitution income or allowance; (b) at least one labour income, referring to children born in families where at least one parent had a paid job.

2.3. Data analysis

Parental characteristics, birth's characteristics, and BF attitude were compared between the two groups: born in BFHI or non‐BFHI maternity facilities (BFHI status). EBF proportions at discharge were compared according to BFHI status and parental characteristics, birth's characteristics, and BF. Chi‐square test and t test were applied to compare prevalences and means (age), respectively. Distributions of education level (ordinal variable) were compared using Mann–Whitney test. For EBF duration (not shown in the tables), only mothers who breastfed at discharge from the maternity facilities were included in the analyses. The EBF duration was based on the week during which EBF was stopped. The median durations and 95% CI of EBF were derived using the Kaplan–Meier curves that were compared with Log‐rank and Breslow test. Epi‐Info (http://6.04d.fr) and SPSS‐IBM Statistics 22 were used for encoding and carrying out all statistical analyses.

3. RESULTS

3.1. Characteristics of the population

From all the families with children aged 18–24 months old originally included in the sample (n = 715), 88% were successfully reached (n = 630). Among them, 11% refused to participate, mainly because of a lack of time or interest (n = 68). Among the remaining families, 88% of mothers or parental couples gave information about BF (n = 557). In the final sample, one quarter of the children were born in a BFHI maternity facility. Table 1 presents the parental sociodemographic characteristics and Table 2 the characteristics of birth and of BF. A total of 75% of mothers were of Belgian nationality origin, 14% of children were born in a household with no labour income, and over 80% of partners had a positive attitude towards BF. The majority of mothers had made the decision to breastfeed before pregnancy (77%). About one mother in three was primiparous. Among the mothers who breastfed, half (54%) experienced difficulties with BF. Overall, the parental sociodemographic, birth, and BF characteristics did not differ significantly between mothers giving birth in BFHI or non‐BFHI maternity facilities.

Table 1.

Distribution of parental sociodemographic characteristics by BFHI status of the maternity where birth took place (%, mean (SD), p value)

Total sample (%), n

BFHI (%)

 Non‐BFHI (%) p value
Mother's nationality of origin
Belgian 75.0 (404) 80.4 73.0 .06
Foreign 25.0 (135) 19.1 27.0
Mother's educational level
≤3 years secondary school 17.5 (94) 14.7 18.5 .9
Completed secondary school 32.3 (173) 36.8 30.8
Graduates studies (but nonuniversity diploma) 32.6 (175) 30.1 33.5
University 17.5 (94) 18.4 17.3
Mother's age (years) mean (SD) 31.0 (17–46) 31.3 (5.4) 31.6 (5.3) .668
Partner's educational level
≤3 years secondary school 21.4 (110) 25.0 20.1 .2
Completed secondary school 38.1 (196) 37.9 38.1
Graduates studies (but non university diploma) 22.3 (115) 20.5 23.0
University 18.3 (94) 16.7 18.8
Household income
No labour income 14.3 (76) 11.3 15.3 .3
At least 1 labour income 85.7 (456) 88.7 84.7
Partner's attitude towards BF
Indifferent/negative 19.7 (101) 17.8 20.4 .5
Positive 80.3 (411) 82.2 79.4
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Abbreviations: BF, breastfeeding; BFHI, Baby‐friendly Hospital Initiative.

Table 2.

Distribution of characteristics of birth and of BF by BFHI status of the maternity where birth took place (%, p value)

Total sample % (n) BFHI (%)

Non‐BFHI (%)

 p value
Mode of delivery
Vaginal 77.6 (416) 79.4 77.0 .6
Caesarean section 22.4 (120) 20.6 23.0
Full term
Yes 93.1 (502) 93.4 93.1
No 6.9 (37) 6.6 6.9 .9
Difficulties with BF among BF women
Yes 53.6 (226) 49.1 55.2 .3
No 46.4 (196) 50.9 44.8
BF experience
Multiparous with prior experience 52.2 (284) 51.5 53.1 .6
Multiparous without prior experience 11.9 (65) 10.3 12.7
Primiparous 35.8 (195) 38.2 34.2
BF intention prior to pregnancy
Yes 76.6 (397) 76.9 76.6 .9
No 23.4 (121) 23.1 23.4
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Abbreviations: BF, breastfeeding; BFHI, Baby‐friendly Hospital Initiative.

3.2. EBF in the total sample

In the total sample, the proportion of mothers who breastfed at birth was 81.7% (78.5, 84.3) and who exclusively breastfed was 74.0% (70.3, 77.6). At discharge, the proportion of the mothers who breastfed was 76.8% (73.3, 80.3) and who exclusively breastfed was 68.6% (64.6, 73.0). The prevalence of EBF at birth was higher for children born in BFHI facilities (79.4% (72.6, 86.2) vs. 72.0% (67.6, 76.3), p = .09) as well as that at discharge (76.5% (69.3, 83.6) vs. 65.8% (61.1, 70.4), p = .02). Among mothers who initiated BF, the median duration of EBF was not significantly different between children born in BFHI and non‐BFHI maternity facilities (15.0 vs. 12.9 weeks, p = .3). The proportion of children who were exclusively breastfed at 5 months (21.7 weeks) was also similar when the mother gave birth in a BFHI maternity facility or not (16.8% vs. 15.8%, p = 1.0) (Not shown in the tables).

3.3. EBF according to parental and birth characteristics

The second column in Tables 3 and 4 presents the proportion of women who breastfed exclusively at discharge among the total of BF women in each specific category. The proportion of mothers who breastfed exclusively at discharge from the maternity facility was significantly higher among mothers of foreign origin, those with a higher level of education (including for the partners), when the household had at least one labour income and when the partner had a positive attitude towards BF. More children who were born vaginally or at full term were also exclusively breastfed at the time of discharge from the maternity facility. The same was observed for children whose mother encountered no difficulty with BF. More primiparous or multiparous with prior experience of BF (compared with multiparous without prior experience) and more mothers who had chosen to breastfeed before becoming pregnant also exclusively breastfed at discharge from the maternity facility.

Table 3.

Proportion of mothers EBF at discharge according to parental characteristics and BFHI status of maternity where birth took place (%, p value)

Total % (n) BFHI (%) Non‐BFHI (%) p value
Mother's nationality of origin (p) (***) (NS) (***)
Belgian 64.4 (260) 75.5 60.2 0.004
Foreign 80.7 (109) 80.8 80.7 1.0
Mother's educational level (p) (***) (**) (***)
≤3 years secondary school* 50.0 (47) 50.0 50.0 1.0
Completed secondary school 68.8 (119) 76.0 65.9 0.2
Graduates studies (but nonuniversity diploma) 69.1 (121) 85.4 64.2 0.01
University 84.0 (79) 84.0 84.1 1.0
Partner's educational level (p) (***) (*) (**)
≤3 years secondary school 60.0 (66) 66.7 57.1 0.3
Completed secondary school 67.3 (132) 74.0 65.1 0.2
Graduates studies (but nonuniversity diploma) 70.4 (81) 88.9 64.8 0.02
University 81.9 (77) 86.4 80.6 0.5
Household income (p) (***) (*) (**)
No labour income 50.0 (38) 53.3 49.1 0.7
At least 1 labour income 71.7 (327) 79.7 68.9 0.03
Partner's attitude towards BF (p; p) (***) (***) (***)
Indifferent/negative 21.8 (22) 43.5 15.4 0.004
Positive 83.9 (345) 88.7 82.3 0.1
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Abbreviations: BF, breastfeeding; BFHI, Baby‐friendly Hospital Initiative; EBF, exclusive breastfeeding.

p values are presented to show significance between the different options in the categories of parental characteristics in the strata (BFHI OR non‐BFHI).Those are shown as follows:

(*)

: p < .05,

(**)

: p < .01,

(***)

: p < .001, (NS): non‐significant

Table 4.

Proportion of mothers EBF at discharge according to characteristics of birth and BF and BFHI status of the maternity where birth took place (%, p value)

Total (%, n) BFHI (%) Non‐BFHI (%) p value
Mode of delivery (p) (**) (*) (NS)
Vaginal 71.6 (298) 80.6 68.5 .02
Caesarean section 59.2 (71) 60.7 58.7 .8
Full term (p) (**) (NS) (**)
Yes 69.9 (317) 77.2 67.5 .04
No 48.6 (18) 66.7 42.9 .2
Difficulties with BF among BF women (p) (***) (**) (**)
Yes 75.2 (170) 80.0 73.7 .3
No 91.3 (179) 96.5 89.2 .1
BF experience (p; p) (***) (***) (***)
Multiparous with prior experience 78.2 (222) 84.3 76.2 .1
Multiparous without prior experience 24.6 (16) 35.7 21.6 .3
Primiparous 68.9 (131) 76.9 65.9 .1
BF intention prior to pregnancy (p) (***) (**) (**)
Yes 75.3 (299) 83.5 72.4 .02
No 57.0 (69) 58.1 56.7 .9
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Abbreviations: BF, breastfeeding; BFHI, Baby‐friendly Hospital Initiative; EBF, exclusive breastfeeding.

p values are presented to show significance between the different options in the categories of birth's characteristics in the strata (BFHI OR non‐BFHI). Those are shown as follows:

(*)

: p < .05,

(**)

: p < .01,

(***)

: p < .001, (NS) non‐significant.

3.4. EBF according to the type of maternity facility

The remaining columns in Tables 3 and 4 present the differences between BFHI and non‐BFHI maternity facilities. Mothers of Belgian origin were more likely to breastfeed when they gave birth in a BFHI maternity facility than in a non‐BFHI maternity facility (75% vs 60%). Eighty‐five percent of mothers with a nonuniversity diploma (higher than secondary school) were EBF when discharged from the BFHI maternity facilities compared with only 64% from the non‐BFHI ones. A similar pattern was observed when the partner had a nonuniversity diploma (89% vs. 65%). Mothers' mean age did not significantly differ according to the type of maternity ward and according to feeding type. When the partner was indifferent or had a negative attitude towards BF, a higher proportion of mothers who gave birth in a BFHI maternity facility were EBF at discharge (43% vs. 15%). Similarly, more mothers who had made a decision about BF prior to pregnancy breastfed exclusively at discharge if they had given birth in a BFHI maternity facility (83% vs. 72%). Though for other characteristics in Tables 3 and 4, no significant difference was observed, in nearly every case, the proportion of mothers who were EBF at discharge was higher among those who had given birth in a BFHI‐certified maternity facility.

3.5. Information and support from health professionals

Data regarding the information or support received from health professionals are not presented in the Tables, but some insights are presented here. Only 24.5% of the mothers gave 6 months as an answer for the optimal duration of EBF (28.6% if gave birth in a BFHI facility vs. 23.1% in a non‐BFHI facility, p = .2). Nearly 58% of mothers mentioned that they felt they had been adequately informed about BF during their stay in the maternity (67.7% vs. 57.5%, p = .03). Less than 60% said they had been informed about the benefits of BF for their child (66.4% vs. 56.9% p = .06), and 43.0% had been informed about the benefits for themselves (51.5% vs. 40.5%, p = .02). One fifth of the mothers reported they had received contradictory information on BF (23.1% vs. 21.1%, p = .7) while in the maternity facility. Almost 20% said they did not feel supported for their choice on infant feeding (BF or not; 13.6% vs. 19.4%, p = .2). In addition, among mothers who encountered difficulties when initiating BF, the EBF rate was not different between BFHI and non‐BFHI maternity facilities (Table 4).

4. DISCUSSION

The present study included a BF module in a periodic immunization survey to obtain data on BF. This is a viable option for many countries, and it requires very limited resources compared with undertaking large separate surveys. Considering (a) the absence of data on the implementation of BFHI in Wallonia, and more broadly in Belgium, (b) the limited available data on BF, and (c) the recommendation in the 2018 revised guidelines for BFHI that external assessments should be carried out every 5 years at the facility level (WHO & Unicef, 2018), this study provides an opportunity to compare prevalences and some other BF information between mothers giving birth in BFHI and non‐BFHI maternity facilities.

4.1. Quality of BF care

Some proxies were used to assess the quality of BF care received by mothers during the maternity stay. First, the difference between the prevalence of EBF at birth and at discharge can be considered as an indicator of BF support by health professionals within the maternity facilities as the quality of BF care is recognized to positively affect BF during the maternity stay. In our study, the decrease in EBF observed between birth and discharge was smaller in BFHI maternity facilities. Second, BF support, information on BF benefits and BF‐recommended durations, and consistency in BF care can also be considered indicators of high‐quality BF care. In this study, those were not significantly different between BFHI and non‐BFHI maternity facilities. In both types, more than 20% of mothers received contradictory messages concerning BF. Also, few mothers knew that EBF was recommended for the first 6 months of life, regardless of the type of maternity facility. Even if mothers appear to be better informed about the benefits of BF for their babies and for themselves in BFHI maternity facilities, this study suggests that there is a need to strengthen the BF knowledge of health professionals and improve their attitude towards BF in all maternity facilities. In Belgium, the lack of BF competencies of health professionals is increasingly being recognized among various health professionals (Réseau Allaitement maternel, 2003).

4.2. Rates, duration of EBF, and importance of community services

In contrast to a previous survey in Wallonia that included children born in 2010 (Robert, Coppieters, Swennen, & Dramaix, 2015), we found a significant difference in EBF at discharge from the maternity facility in favour of BFHI, though the duration of EBF was not significantly longer. Whereas some studies show a positive effect of BFHI on EBF duration (Broadfoot, Britten, Tappin, & MacKenzie, 2005; DiGirolamo, Grummer‐Strawn, & Fein, 2001; Merten, Dratva, & Ackermann‐Liebrich, 2005), others do not, suggesting that BFHI in itself appears insufficient to increase the duration of EBF (Bartington, Griffiths, Tate,, & Dezateux, 2006; Braun et al., 2003; Brodribb, Kruske, & Miller, 2013; Hawkins, Stern, Baum, & Gillman, 2014). Interventions limited to the maternity facility may increase the rates of initiation of BF but may have only a short‐term effect unless complementary strategies are implemented (Bosnjak, Batinica, Hegedus‐Jungvirth, Grgurić, & Bozikov, 2004; Braun et al., 2003; Coutinho, de Lira, de Carvalho Lima, & Ashworth, 2005). In a systematic review of the impact of BFHI, community support was key for sustaining short‐term BF benefits obtained from BFHI (Pérez‐Escamilla, Martinez, & Segura‐Pérez, 2016). In another review of the effectiveness of primary care interventions to promote BF, the authors concluded that combined prenatal and postnatal interventions and inclusion of lay support (e.g., peer support or peer counselling) in a multicomponent intervention appears beneficial to increase both short‐ and long‐term BF rates (Chung et al., 2008). Greatest improvements in EBF rates and continued BF were seen when counselling or education were provided concurrently at home and in the community, by health care providers and community workers (Sinha et al., 2015). In the Wallonian context, little adequate BF support exists (except for lactation consultants or limited advice available by phone). In an earlier study, we observed that perceived milk insufficiency, breast engorgement, and cracked nipples accounted for more than 45% of reasons for weaning during the first 3 months (Robert, Coppieters, Swennen, & Dramaix, 2014a, 2014b). These issues do require trained personnel, which is scarce in Belgium, (Benahmed, 2014), as in other countries (Morris, 2014; Pound, Williams, Grenon, Aglipay, & Plint, 2014; Sims, Long, Tender, & Young, 2015).

4.3. BFHI: A booster or a trigger?

Authors have suggested that “if Baby‐friendly hospitals improve BF conditions for all women, then those with traditionally lower BF rates would be expected to have above‐average BF rates in the BFHI setting” (Merewood, Mehta, Chamberlain, Philipp, & Bauchner, 2005). In contrast to this and to others (Hawkins et al., 2014), we observed no significant difference between the EBF prevalences for babies born in BFHI and non‐BFHI maternity facilities for mothers generally less likely to BF or to EBF (mothers with lower education, no labour income, caesarean section, no BF decision prior to pregnancy). However, there were two exceptions to this for the EBF prevalences: When partners had an indifferent or negative attitude towards BF and in mothers of Belgian origin nationality. Traditionally in Belgium, those tend to have lower BF rates (Office de la Naissance et de l'Enfance, 2004), as in France (Bonet, L'hélias, & Blondel, 2008) and Ireland (Ladewig, Hayes, Browne, Layte, & Reulbach, 2014). Our study confirmed this trend. However, when stratifying this in our analyses, we observed higher EBF prevalences among Belgian origin women who had given birth in BFHI maternity facilities and no difference in women of foreign origin. One relevant question is, could BFHI particularly act as a trigger to increase EBF practices among Belgian origin mothers? The same question could be asked when partners have an indifferent or negative attitude towards BF. Furthermore, rates were higher in BFHI maternity facilities among women having a vaginal delivery, delivering at full term, also in those in which a decision regarding feeding type was made prior to pregnancy and in families with at least one labour income. These “favourable” characteristics are usually associated with higher BF rates (Ibanez et al., 2012; Thulier & Mercer, 2009). In such favourable cases, BFHI maternity facilities could act as a booster, reinforcing the convictions of the already convinced mothers. On this issue, the maternity facilities that have more women with a favourable BF profile may obtain the BFHI label more easily for which a 75% rate of EBF at discharge was a prerequisite. A retrospective cross‐sectional study like ours indeed does not allow excluding that the differences in EBF rates already existed in some subgroups before the BFHI labelling process. A direct causal link has not been demonstrated in a number of studies that show the influence of BFHI implementation (Atchan, Davis, & Foureur, 2013). Moreover, a recent literature review on BFHI to improve BF rates concluded the following:

“A majority of the studies that assessed the effect of the BFHI did find that the program had a positive influence on breastfeeding outcomes. Of note, however, is that an increase in exclusive breastfeeding in the hospital is a criterion for Baby‐friendly certification. Thus, concluding that the intervention increases breastfeeding initiation employs a circular logic because the intervention itself cannot also be a measured outcome” (Howe‐Heyman & Lutenbacher, 2016, p.100).

On this regard, some countries like the United Kingdom or France do not use the international 75% criterion for accreditation (Malik & Cutting, 1998) to avoid a self‐selection effect. Scepticism towards the methodologies used to assess the impact of BFHI policies have increased over the years (Atchan et al., 2013; Bartington, Griffiths, Tate,, & Dezateux, 2006; Howe‐Heyman & Lutenbacher, 2016; Merewood et al., 2005; Munn, Newman, Mueller, Phillips, & Taylor, 2016; Patnode, Henninger, Senger, Perdue, & Whitlock, 2016) and with that, the impact of BFHI has been increasingly questioned (Brodribb et al., 2013; Gomez‐Pomar & Blubaugh, 2018; Howe‐Heyman & Lutenbacher, 2016). Prospective studies are needed to examine causal factors associated with increased or decreased BF rates within baby‐friendly hospitals (Merewood et al., 2005; Munn et al., 2016). Like these authors, we think that a universal rate‐tracking system is needed to examine not only the effectiveness of the BFHI strategy but also to monitor the various aspects of its implementation. Without such data, monitoring progress over time is almost impossible.

4.4. Unintended consequences

On top of the methodological issues, requiring a minimum EBF rate for labelling in a country with relatively low BF rates, like Belgium, could penalize maternity facilities with the lowest EBF rates and that would most benefit from an effective BF supportive environment. Some years ago, Malik and Cutting suggested that hospitals might be discouraged by unachievable targets. In order to support poor areas to apply for BFHI labelling, the United Kingdom has lowered EBF rate requirements for BFHI certification (Malik & Cutting, 1998; Radford, Rickitt, & Williams, 1998). More recently, France has adopted a national BFHI label that does not set a minimum EBF rate. For the national French BFHI labelling, EBF rates are compared with departmental statistics, taking into account local specificities. Indeed, it has been recently proven not effective to initiate and support BF initiatives without adapting these to the local BF rates, needs, and beliefs (Gomez‐Pomar & Blubaugh, 2018). Other countries like Belgium may need to implement a similar policy to get hospitals in impoverished areas to apply for BFHI labelling. Action is needed in the most disadvantaged socioeconomic regions in order not to reinforce health inequality. Global initiatives such as the BFHI may require adaptations to the local, national, and regional realities in order to be most effective, and they need to evolve over time according to the evolving contexts.

4.5. Strengths and limitations

The study presents several strengths. The population sample was representative of the Wallonian region. The sociodemographics data were comparable (except for the educational level) with the regional databases of Perinatal Epidemiology Centre (Leroy, Van Leeuw, Zhang, & Englert, 2016). In addition, the rate of any BF at birth (81.7% (78.5–84.9) was identical (81.2%) to that measured when analysing electronic birth certificates (E‐birth) in that region.

The study also presents several limitations. First, the mothers were interviewed 18 to 24 months after delivery, thus bringing potential recall bias. However, previous studies indicate that the recall of BF initiation and duration is more accurate than recall of introduction of complementary foods (Li, Scanlon, & Serdula, 2005). Even if recall bias cannot be completely ruled out, it is unlikely that it would affect differently the type of maternity facility (BFHI vs non‐BFHI). Second, the rather small number of people included in some categories (preterm infant, multiparous without prior BF experience, etc.) decreased statistical power.

5. CONCLUSION

In Belgium, the BFHI seems to act as a booster in women who are already motivated to BF, but the Initiative does not seem to act as a trigger to improve BF practice in women and couples less traditionally likely to do so. It may also be that the convinced women themselves boost EBF rates in some maternity facilities, enabling them to obtain BFHI accreditation more easily than others. In any case, in Belgium, the BFHI is a device that is far from sufficient to promote and support BF in groups less likely to BF. Therefore, there is an urgent need for advocacy actions to ensure that policymakers in this country become aware of the value of investing in the promotion, support, and protection of BF, in order to develop strong policies to improve the rates, duration, and support for BF, particularly for the most vulnerable women.

CONFLICTS OF INTEREST

The authors declare that they have no conflict of interest.

CONTRIBUTIONS

ER and BS conceptualized the study and played leadership roles throughout all stages of the study. ER and MD conducted data analysis. ER, IML, and RD conducted interpretation of the results and drafting of the different sections of the manuscript. IML revised the narrative and English language as requested by the reviewers. ER, IML, BS, and RD read, commented, and approved the final manuscript.

ACKNOWLEDGMENTS

The authors thank all the families who took part in this survey and Micheline Beaudry for her insightful feedback on drafts of this manuscript. They also thank the anonymous reviewers for their time and valuable comments.

Robert E, Michaud‐Létourneau I, Dramaix‐Wilmet M, Swennen B, Devlieger R. A comparison of exclusive breastfeeding in Belgian maternity facilities with and without Baby‐friendly Hospital status. Matern Child Nutr. 2019;15:e12845 10.1111/mcn.12845

Footnotes

REFERENCES

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