The effects of rooming-in on the success of breastfeeding and the decline in abandonment of children

Breastfeeding and infant care as 'sexed' care work: reconsideration of the three Rs to enable women's rights, economic empowerment, nutrition and health

Women's lifelong health and nutrition status is intricately related to their reproductive history, including the number and spacing of their pregnancies and births, and for how long and how intensively they breastfeed their children. In turn, women's reproductive biology is closely linked to their social roles and situation, including regarding economic disadvantage and disproportionate unpaid work. Recognizing, as well as reducing and redistributing women's care and domestic work (known as the 'Three Rs'), is an established framework for addressing women's inequitable unpaid care work. However, the care work of breastfeeding presents a dilemma, and is even a divisive issue, for advocates of women's empowerment, because reducing breastfeeding and replacing it with commercial milk formula risks harming women's and children's health. It is therefore necessary for the interaction between women's reproductive biology and infant care role to be recognized in order to support women's human rights and enable governments to implement economic, employment and other policies to empower women. In this paper, we argue that breastfeeding-like childbirth-is reproductive work that should not be reduced and cannot sensibly be directly redistributed to fathers or others. Rather, we contend that the Three Rs agenda should be reconceptualized to isolate breastfeeding as 'sexed' care work that should be supported rather than reduced with action taken to avoid undermining breastfeeding. This means that initiatives toward gender equality should be assessed against their impact on women's ability to breastfeed. With this reconceptualization, adjustments are also needed to key global economic institutions and national statistical systems to appropriately recognize the value of this work. Additional structural supports such as maternity protection and childcare are needed to ensure that childbearing and breastfeeding do not disadvantage women amidst efforts to reduce gender pay gaps and gender economic inequality. Distinct policy interventions are also required to facilitate fathers' engagement in enabling and supporting breastfeeding through sharing the other unpaid care work associated with parents' time-consuming care responsibilities, for both infants and young children and related household work.

Care Through the Newborn's Eyes

Separation of mothers and infants after birth is standard practice for many hospitals, yet not evidence-based. Nonseparation clearly has numerous benefits. However, newborns lack a voice to make choices to direct their course of care. The evidence supports nonseparation strategies for mothers and infants that promote attachment, physiologic regulation, nutrition, sleep, communication, and management of stress/pain. Moreover, the evidence is compelling that nonseparation is essential. The time has come to act on the evidence and begin seeing the care we provide through the newborn's eyes.

Integrated Interventions Delivered in Health Systems, Home, and Community Have the Highest Impact on Breastfeeding Outcomes in Low- and Middle-Income Countries

Background: Improving breastfeeding rates is critical. In low- and middle-income countries (LMICs), only subtle improvements in breastfeeding rates have been observed over the past decade, which highlights the need for accelerating breastfeeding promotion interventions.Objective: The objective of this article is to update evidence on the effect of interventions on early initiation of and exclusive (<1 and 1-5 mo) and continued (6-23 mo) breastfeeding rates in LMICs when delivered in health systems, in the home or in community environments, or in a combination of settings.Methods: A systematic literature search was conducted in PubMed, Cochrane, and CABI databases to identify new articles relevant to our current review, which were published after the search date of our earlier meta-analysis (October 2014). Nine new articles were found to be relevant and were included, in addition to the other 52 studies that were identified in our earlier meta-analysis. We reported the pooled ORs and corresponding 95% CIs as our outcome estimates. In cases of high heterogeneity, random-effects models were used and causes were explored by subgroup analysis and meta-regression.Results: Early initiation of and exclusive (<1 and 1-5 mo) and continued (6-23 mo) breastfeeding rates in LMICs improved significantly as a result of interventions delivered in health systems, in the home or community, or a combination of these. Interventions delivered concurrently in a combination of settings were found to show the largest improvements in desired breastfeeding outcomes. Counseling provided in any setting and baby-friendly support in health systems appear to be the most effective interventions to improve breastfeeding.Conclusions: Improvements in breastfeeding practices are possible in LMICs with judicious use of tested interventions, particularly when delivered in a combination of settings concurrently. The findings can be considered for inclusion in the Lives Saved Tool model.

Rooming-in for new mother and infant versus separate care for increasing the duration of breastfeeding

BACKGROUND

Mother-infant proximity and interactions after birth and during the early postpartum period are important for breast-milk production and breastfeeding success. Rooming-in and separate care are both traditional practices. Rooming-in involves keeping the mother and the baby together in the same room after birth for the duration of hospitalisation, whereas separate care is keeping the baby in the hospital nursery and the baby is either brought to the mother for breastfeeding or she walks to the nursery.

OBJECTIVES

To assess the effect of mother-infant rooming-in versus separation on the duration of breastfeeding (exclusive and total duration of breastfeeding).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 May 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials (RCTs) investigating the effect of mother-infant rooming-in versus separate care after hospital birth or at home on the duration of breastfeeding, proportion of breastfeeding at six months and adverse neonatal and maternal outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion and assessed trial quality. Two review authors extracted data. Data were checked for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included one trial (involving 176 women) in this review. This trial included four groups with a factorial design. The factorial design took into account two factors, i.e. infant location in relation to the mother and the type of infant apparel. We combined three of the groups as the intervention (rooming-in) group and the fourth group acted as the control (separate care) and we analysed the results as a single pair-wise comparison. Primary outcomesThe primary outcome, duration of any breastfeeding, was reported by authors as median values because the distribution was found to be skewed. They reported the overall median duration of any breastfeeding to be four months, with no difference found between groups. Duration of exclusive breastfeeding and the proportion of infants being exclusively breastfed at six months of age was not reported in the trial. There was no difference found between the two groups in the proportion of infants receiving any breastfeeding at six months of age (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.51 to 1.39; one trial; 137 women; low-quality evidence). Secondary outcomesThe mean frequency of breastfeeds per day on day four postpartum for the rooming-in group was 8.3 (standard deviation (SD) 2.2), slightly higher than the separate care group, i.e. seven times per day. However, between-group comparison of this outcome was not appropriate since every infant in the separate care group was breastfed at a fixed schedule of seven times per day (SD = 0) resulting in no estimable comparison. The rate of exclusive breastfeeding on day four postpartum before discharge from hospital was significantly higher in the rooming-in group 86% (99 of 115) compared with separate care group, 45% (17 of 38), (RR 1.92; 95% CI 1.34 to 2.76; one trial, 153 women; low-quality evidence). None of our other pre-specified secondary outcomes were reported.

AUTHORS' CONCLUSIONS

We found little evidence to support or refute the practice of rooming-in versus mother-infant separation. Further well-designed RCTs to investigate full mother-infant rooming-in versus partial rooming-in or separate care including all important outcomes are needed.

Interventions to improve breastfeeding outcomes: a systematic review and meta-analysis

AIM

To provide comprehensive evidence of the effect of interventions on early initiation, exclusive, continued and any breastfeeding rates when delivered in five settings: (i) Health systems and services (ii) Home and family environment (iii) Community environment (iv) Work environment (v) Policy environment or a combination of any of above.

METHODS

Of 23977 titles identified through a systematic literature search in PUBMED, Cochrane and CABI, 195 articles relevant to our objective, were included. We reported the pooled relative risk and corresponding 95% confidence intervals as our outcome estimate. In cases of high heterogeneity, we explored its causes by subgroup analysis and meta-regression and applied random effects model.

RESULTS

Intervention delivery in combination of settings seemed to have higher improvements in breastfeeding rates. Greatest improvements in early initiation of breastfeeding, exclusive breastfeeding and continued breastfeeding rates, were seen when counselling or education were provided concurrently in home and community, health systems and community, health systems and home settings, respectively. Baby friendly hospital support at health system was the most effective intervention to improve rates of any breastfeeding.

CONCLUSION

To promote breastfeeding, interventions should be delivered in a combination of settings by involving health systems, home and family and the community environment concurrently.

Histone deacetylase inhibition induces long-lasting changes in maternal behavior and gene expression in female mice

In many species, including mice, maternal responsiveness is experience-dependent and permanent, lasting for long periods (months to years). We have shown that after brief exposures to pups, virgin female mice continue to respond maternally toward pups for at least one month. Administration of a histone deacetylase inhibitor (HDACi) reduces the amount of maternal experience required to affect maternal behavior and gene expression. In this set of studies, we examined the epigenetic mechanisms that underlie these motivated behaviors. We assessed whether the effects of HDACi persisted 1 month after the initial experience (in the absence of continued pup experience or HDACi treatment) and whether the maintenance of maternal memory was associated with stable changes in gene expression. Using chromatin immunoprecipitation, we examined whether Esr2 and Oxt gene expression might be mediated by recruitment of the histone acetyltransferase cAMP response element binding protein (CBP) to their promoter regions after maternal memory consolidation. We report that HDACi treatment induced long-lasting changes in maternal responsiveness. Maternal learning was associated with increased recruitment of CBP to the Esr2 and Oxt gene promoters during the consolidation of maternal memory as well as a persistent increase in estrogen receptor-β (Esr2) mRNA and decreased expression of the de novo DNA methyltransferase Dnmt3a within the medial preoptic area. The consolidation of the maternal experience may involve the CBP recruitment and stable changes in gene expression, which maintain increased maternal responsiveness for long periods of time.

Is "Bed Sharing" Beneficial and Safe during Infancy? A Systematic Review

Background. There is conflicting evidence regarding the safety and efficacy of bed sharing during infancy-while it has been shown to facilitate breastfeeding and provide protection against hypothermia, it has been identified as a risk factor for SIDS. Methods. A systematic search of major databases was conducted. Eligible studies were observational studies that enrolled infants in the first 4 weeks of life and followed them up for a variable period of time thereafter. Results. A total of 21 studies were included. Though the quality of evidence was low, bed sharing was found to be associated with higher breastfeeding rates at 4 weeks of age (75.5% versus 50%, OR 3.09 (95% CI 2.67 to 3.58), P = 0.043) and an increased risk of SIDS (23.3% versus 11.2%, OR 2.36 (95% CI 1.97 to 2.83), P = 0.025). Majority of the studies were from developed countries, and the effect was almost consistent across the studies. Conclusion. There is low quality evidence that bed sharing is associated with higher breast feeding rates at 4 weeks of age and an increased risk of SIDS. We need more studies that look at bed sharing, breast feeding, and hazardous circumstance that put babies at risk.

Effect of breastfeeding promotion interventions on cost-effectiveness of rotavirus immunization in Indonesia

BACKGROUND

Rotavirus infection has been reported to be responsible for the majority of severe diarrhea in children under-5-years-old in Indonesia. Breast milk is considered to give protection against rotavirus infection. Increasing breastfeeding promotion programs could be an alternative target to reduce the incidence of rotavirus diarrhea. This study aims to investigate the effect of breastfeeding promotion interventions on cost-effectiveness of rotavirus immunization in Indonesia, focusing on breastfeeding education and support interventions.

METHODS

An age-structured cohort model was developed for the 2011 Indonesia birth cohort. We compared four interventions in scenarios: (i) base-case (I₀) reflecting the current situation for the population of under-5-years-old, (ii) with an additional breastfeeding education intervention (I₁), (iii) with a support intervention on initiation and duration (I₂) and (iv) with both of these two interventions combined (I₃). The model applied a 5-years time horizon, with 1 month analytical cycles for children less than 1 year of age and annually thereafter. Monte Carlo simulations were used to examine the economic acceptability and affordability of rotavirus vaccination.

RESULTS

Rotavirus immunization would effectively reduce severe cases of rotavirus during the first 5 years of a child's life even assuming various breastfeeding promotion interventions. The total yearly vaccine cost would amount to US$ 64 million under the market vaccine price. Cost-effectiveness would increase to US$ 153 per quality-adjusted-life-year (societal perspective) with an optimal breastfeeding promotion intervention. Obviously, this is much lower than the 2011 Gross Domestic Product (GDP) per capita of US$ 3,495. Affordability results showed that at the market vaccine price, rotavirus vaccination could be affordable for the Indonesian health system.

CONCLUSIONS

Rotavirus immunization would be a highly cost-effective public health intervention for Indonesia even under various breastfeeding promotion interventions based on the WHO's criteria for cost-effectiveness in universal immunization.

Separate care for new mother and infant versus rooming-in for increasing the duration of breastfeeding

BACKGROUND

Separate care for a new mother and infant may affect the duration of breastfeeding, breastfeeding behaviour and may have an adverse effect on neonatal and maternal outcomes.

OBJECTIVES

To assess the effect of mother-infant separation versus rooming-in on the duration of breastfeeding (exclusive and total duration of breastfeeding).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2012).

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials (RCTs) investigating the effect of separate mother-infant care versus rooming-in after hospital birth or at home on the duration of breastfeeding, proportion of breastfeeding at six months and adverse neonatal and maternal outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion and assessed trial quality. Two review authors extracted data. Data were checked for accuracy.

MAIN RESULTS

There were 23 reports from 19 potential trials identified. After assessment, one trial (involving 176 women) met our inclusion criteria.One trial reported an overall median duration of any breastfeeding of four months. Exclusive breastfeeding before discharge from hospital (at day four postpartum) was significantly lower in the separate care group compared with the rooming-in group (risk ratio (RR) 0.58; 95% CI 0.42 to 0.81; one trial, 141 women). 

AUTHORS' CONCLUSIONS

We found little evidence to support or refute the practice of mother-infant separation versus rooming-in. Therefore, we see no reason to practise it. We recommend a well designed RCT to investigate full mother-infant rooming-in versus partial rooming-in or separate care on all of the primary and secondary outcomes suggested.

Global baby-friendly hospital initiative monitoring data: update and discussion

BACKGROUND

The World Health Organization (WHO)/UNICEF Baby-Friendly Hospital Initiative (BFHI) was developed to support the implementation of the Ten Steps for Successful Breastfeeding. The purpose of this study is to assess trends in the numbers facilities ever-designated "baby-friendly," to consider uptake of the new WHO/UNICEF BFHI materials, and to consider implications for future breastfeeding support.

MATERIALS AND METHODS

The national contacts from the 2006-2007 UNICEF BFHI update were recontacted, as were WHO and UNICEF officers worldwide, to ascertain the number of hospitals ever-designated "baby-friendly," presence of a government breastfeeding oversight committee, use of the new BFHI materials and, if yes, use of the new maternity or human immunodeficiency virus (HIV) materials.

RESULTS

Seventy countries reporting in 2010-2011 and the updates from an additional 61 reporting in 2006-2007 (n=131, or 66% of the 198 countries) confirm that there are at least 21,328 ever-designated facilities. This is 27.5% of maternities worldwide: 8.5% of those in industrialized countries and 31% in less developed settings. In 2010, government committees were reported by 18 countries, and 34 reported using the new BFHI materials: 14 reported using the maternity care and 11 reported using the HIV materials.

CONCLUSIONS

Rates of increase in the number of ever-certified "baby-friendly" hospitals vary by region and show some chronological correlation with trends in breastfeeding rates. Although it is not possible to attribute this increase to the BFHI alone, there is ongoing interest in Ten Steps implementation and in BFHI. The continued growth may reflect the dedication of ministries of health and national BFHI groups, as well as increasing recognition that the Ten Steps are effective quality improvement practices that increase breastfeeding and synergize with community interventions and other program efforts. With renewed interest in maternal/neonatal health, revitalization of support for Ten Steps and their effective institutionalization in maternity practices should be considered. Future updates are planned to assess ongoing progress and impact, and ongoing updates from national committees are welcome.

Experience-facilitated improvements in pup retrieval; evidence for an epigenetic effect

The quality and quantity of maternal care received during infancy are highly predictive of successful infant development. It has been well established, primarily in rats, that the combination of hormonal and infant stimuli at birth modifies neural circuits that regulate maternal responsiveness. During subsequent interactions, infant stimuli are more likely to elicit rapid maternal responsiveness. Some species, such as humans, can display maternal care in the absence of the endocrine events of pregnancy and birth. Similarly, virgin C57BL/6J female mice, display maternal care toward infants, and experience with infants elicits long-lasting increases in maternal care. We hypothesized that these experience-induced changes in behavior may be mediated by chromatin modifications, which in turn change expression of genes that promote maternal care. One site of action is the medial preoptic area (MPOA). To test our hypothesis we treated virgin female mice with sodium butyrate, a histone deacetylase inhibitor. This treatment potentiated maternal responsiveness as well as the expression of several genes: estrogen receptor β (Esr2), oxytocin (Oxt), and cyclicAMP response element binding protein (CREB) binding protein (Crebbp; a histone acetyltransferase) in the MPOA. These data suggest that experience induces high levels of maternal care via epigenetic modifications.

Neonatal handling affects durably bonding and social development

The neonatal period in humans and in most mammals is characterized by intense mother-young interactions favoring pair bonding and the adaptation of neonates to their new environment. However, in many post-delivery procedures, human babies commonly experience combined maternal separation and intense handling for about one hour post-birth. Currently, the effects of such disturbances on later attachment and on the development of newborns are still debated: clearly, further investigations are required. As animals present good models for controlled experimentation, we chose domestic horses to investigate this issue. Horses, like humans, are characterized by single births, long lactating periods and selective mother-infant bonds. Routine postnatal procedures for foals, as for human babies, also involve intense handling and maternal separation. In the present study, we monitored the behavior of foals from early stages of development to "adolescence", in a normal ecological context (social groups with adults and peers). Experimental foals, separated from their mothers and handled for only 1 hour post-birth, were compared to control foals, left undisturbed after birth. Our results revealed short- and long-term effects of this unique neonatal experience on attachment and subsequent social competences. Thus, experimental foals presented patterns of insecure attachment to their mothers (strong dependence on their mothers, little play) and impaired social competences (social withdrawal, aggressiveness) at all ages. We discuss these results in terms of mother-young interactions, timing of interactions and relationships between bonding and subsequent social competences. Our results indicate that this ungulate species could become an interesting animal model. To our knowledge, this is the first clear demonstration that intervention just after birth affects bonding and subsequent social competences (at least until "adolescence"). It opens new research directions for studies on both humans and other animals.

Does breastfeeding protect against substantiated child abuse and neglect? A 15-year cohort study

OBJECTIVES

We explored whether breastfeeding was protective against maternally perpetrated child maltreatment.

METHODS

A total of 7223 Australian mother-infant pairs were monitored prospectively over 15 years. In 6621 (91.7%) cases, the duration of breastfeeding was analyzed with respect to child maltreatment (including neglect, physical abuse, and emotional abuse), on the basis of substantiated child protection agency reports. Multinomial logistic regression was used to compare no maltreatment with nonmaternal and maternally perpetrated maltreatment and to adjust for confounding in 5890 cases with complete data (81.5%). Potential confounders included sociodemographic factors, pregnancy wantedness, substance abuse during pregnancy, postpartum employment, attitudes regarding infant caregiving, and symptoms of anxiety or depression.

RESULTS

Of 512 children with substantiated maltreatment reports, >60% experienced > or =1 episode of maternally perpetrated abuse or neglect (4.3% of the cohort). The odds ratio for maternal maltreatment increased as breastfeeding duration decreased, with the odds of maternal maltreatment for nonbreastfed children being 4.8 times the odds for children breastfed for > or =4 months. After adjustment for confounding, the odds for nonbreastfed infants remained 2.6 times higher, with no association seen between breastfeeding and nonmaternal maltreatment. Maternal neglect was the only maltreatment subtype associated independently with breastfeeding duration.

CONCLUSION

Among other factors, breastfeeding may help to protect against maternally perpetrated child maltreatment, particularly child neglect.

A Model for Caregiving of Adopted Children After Institutionalization

TOPIC

Optimizing caregiving for newly adopted postinstitutionalized children.

PURPOSE

To consider a template of care for postinstitutionalized children based on experiences that physiological measures suggest are expected by infants postbirth.

SOURCES

Published literature and clinical experience.

CONCLUSION

Based on an understanding of physiologically expected care postbirth, special care for postinstitutionalized adopted children might include: close physical contact via use of a sling and cosleeping; breastfeeding or nurturing through food; and responsive caregiving. In replicating earlier missed experiences, parents may assist emotional development in their child and promote attachment development.

Breastfeeding: a woman's reproductive right

This paper explores the importance of breastfeeding as a women's issue in the health and political contexts, covering the role of global institutions, health practitioners, and national decision-makers in furthering the goals of supporting breastfeeding as a woman's right to health. The roles and responsibilities of the Obstetrician/Gynecologist are highlighted.

When mothers leave their children behind

Psychiatry has studied the effect on children of separation from their mothers or primary caregivers, but has not given equal attention to the effect on mothers of separation from their children. This article examines the current literature on separation from the mother's perspective. Following a review of the literature on mothers' attachment behaviors, as evidenced by separation from their very young children due to ordinary circumstances, attention will turn to specific populations of mothers enduring separation from their children in situations of hardship: mothers with mental illness, homeless mothers, mothers in prison, and two groups of working mothers-immigrant mothers and deployed navy mothers. Separation can be experienced as temporary, bringing on anxiety, or may involve a mother's choice between her child's safety and her own wish to keep the child near her, causing a conflict in the mother's feelings. In other situations, separation may be involuntary and long-lasting, inducing symptoms of depression, despair, and grief, all of which are characteristic of loss. The particular conditions of the separation-such as choice, control, and ongoing communication between mother and child-can mitigate the impact of the separation and transform it from a total to a partial loss. Three clinical cases of mothers forced to separate from their children in extreme circumstances are examined, with recommendations for treatment.

Starting the process of mother-infant bonding

Establishing a bond between a mother and her newborn is essential for the infant to grow and thrive in the mother's care. Hospital staff can promote the creation of this bond by providing continuous support during labor, by placing the newborn skin-to-skin on the mothers chest immediately after delivery until the infant latches on for the first feeding, by encouraging continued breast feeding and by keeping her mother and infant always together in the first hours and days after delivery.

CONCLUSION

Even in case where the mother initially rejects her infant, sensitive medical personnel can provide an environment which allows the bond between mother and infant to begin.

Baby friendly hospital practices: cesarean section is a persistent barrier to early initiation of breastfeeding

BACKGROUND

Documented barriers to the implementation of Step 4 of the Baby Friendly Hospital Initiative, which relates to early initiation of breastfeeding, have not considered the impact of operative intervention in delivery on achievement of the goal. This study was designed to test the hypothesis that hospital practices in the immediate postpartum period that are associated with operative intervention in delivery can affect first mother-infant contact and initiation of breastfeeding.

METHODS

In a prospective, longitudinal study, a sociodemographically representative sample of 203 primiparous women was recruited. Participants were interviewed at 2 days postpartum in metropolitan hospitals in Melbourne, Australia, and medical records were inspected. At 8 months postpartum 81 percent of participants completed a postal questionnaire. Three mode-of-delivery groups (spontaneous vaginal delivery, instrumentally assisted vaginal delivery and cesarean section) and 4 hospital-of-delivery groups (including one accredited Baby Friendly Hospital) were compared.

RESULTS

Two way ANOVA revealed that women who had a cesarean section experienced a significant delay in initiating breastfeeding compared with women giving birth vaginally, with or without instrumental assistance (p < 0.001). Significant differences in this aspect of care were also observed among hospitals, with the Baby-Friendly hospital performing significantly better than the other three hospitals (p < 0.001). An effect due to mode of delivery alone was demonstrated that could not be abolished by differences in hospital practices (p = 0.231). Nevertheless, shorter elapsed time between birth and initiation of breastfeeding was not significantly associated with continuation of breastfeeding at 8 months postpartum (p = 0.642).

CONCLUSIONS

The findings confirmed that cesarean section was a significant barrier to the implementation of Baby Friendly Hospital Initiative Step 4 and that hospital practices were amenable to changes that enabled its implementation regardless of the mode of delivery.

Breastfeeding and women's health

Breastfeeding often is promoted mainly as an infant health issue, with little if any mention of its importance to the mother's health. Despite its significant impact on women's health, breastfeeding is rarely emphasized in women's health programs. This article reviews the current medical literature regarding women's health aspects of breastfeeding, including medical, psychosocial, and environmental issues. Strategies for increasing health care professionals' awareness and promotion of breastfeeding as a women's health issue are discussed in the hope of reversing the worldwide decline in breastfeeding.

Ten steps to successful breastfeeding: a summary of the rationale and scientific evidence

Ample evidence is available on the impact of health care practices and hospital routines and procedures on breastfeeding. Good practices enhance successful initiation and establishment of breastfeeding and contribute to increased duration, just as inappropriate practices, and failure to support and encourage mothers, have the opposite effect. In 1991 the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) jointly launched the Baby-Friendly Hospital Initiative, which aims to give every baby the best start in life by ensuring a health care environment where breastfeeding is the norm. The initiative is based on the principles summarized in a joint statement issued by the two organizations in 1989 on the role of maternity services in protecting, promoting, and supporting breastfeeding. To become truly baby-friendly, hospitals and maternity wards around the world are giving practical effect to the principles described in the joint WHO/UNICEF statement that have been synthesized into Ten Steps To Successful Breastfeeding. This summary of the rationale and scientific basis for the Ten Steps is presented in the light of cumulative experience demonstrating the crucial importance of these principles for the successful initiation and establishment of breastfeeding.