The impact of the Baby-Friendly Hospital Initiative on breastfeeding rates in maternity units in France

Firstly, it is important to emphasise that the BFHI-accredited maternity units included in our assessment are not distributed evenly across the country, in fact the majority are concentrated in northern France. This meant that a key part of this evaluation would involve taking into account the inequalities that exist in the different regions.  

We used data from the 2010, 2016 and 2021 National Perinatal Surveys in France, each of which included more than 10,000 births (13,075, 10,919 and 10,209 respectively). The BFHI maternity units included were the 49 already accredited in mainland France. Those in the process of obtaining certification were considered non-accredited (20 in 2010, 40 in 2016 and 31 in 2021). The online database of the French National Institute of Statistics and Economic Studies (INSEE) was used to obtain data on the French departments and their characteristics. 

We used a series of five mixed-effects multinomial regression models, with adjustment covariates gradually added: 1) maternity unit with BFHI status (yes/no) and survey year; 2) characteristics of the infant and the mother; 3) characteristics of the maternity unit; 4) characteristics of the French department and the spatial random effect; 5) interaction terms. In model 4, looking at the spatial random effect at department level meant we could take into account the variation in breastfeeding rates between departments and the correlation between breastfeeding rates in neighbouring departments. By further adjusting the model on the basis of variables relating to the French department and the random effect, the positive impact of the BFHI initiative on breastfeeding rates became clearer. This can be explained by the large variations in breastfeeding between regions in mainland France and by the fact that maternity units with BFHI accreditation are unevenly distributed across the country. This meant that it was essential to adjust the spatial structure of the data to isolate the effect of the BFHI. In particular, the random spatial effect accounted for more variability in the model than the chosen departmental variables (percentage of population that are migrants, percentage with a university education).
 

In BFHI-accredited maternity units, the gross rates of exclusive breastfeeding were higher than in non-accredited maternity units, while the gross rates of mixed feeding were lower than in non-accredited maternity units. The same applies to rates adjusted for the variables mentioned above, in all models. However, the gross rate of breastfeeding of any kind was lower in accredited maternity units, but when adjusted to take into account individual covariates (maternal age, level of education, country of birth, marital status, situation in late pregnancy, household income, parity, body mass index, mode of delivery, time between delivery and interview, birth weight, gestational age, neonatal transfer) the rate was higher. This difference shows that there was variation between mothers giving birth in BFHI maternity units and those giving birth in non-accredited maternity units in terms of factors associated with breastfeeding. 

In our study, low birth weight babies were breastfed less than average weight babies in both BFHI-accredited and non-accredited maternity units. This is in line with previous studies carried out in France, Spain and Brazil (1-3). We found that the increase in the rates of exclusive breastfeeding and the drop in rates of mixed feeding associated with BFHI accreditation impacted low birth weight newborns more significantly, helping to shrink the gap between this vulnerable group and normal weight babies. 

BFHI accreditation had a positive impact on breastfeeding rates among mothers with a medium to high level of education (two or more years of higher education). For mothers with no education (no schooling at all) or a primary education, accounting for around 2% of the study sample, the rate of exclusive breastfeeding was lower in accredited maternity units, although with a wide confidence interval. These mothers are part of a minority group with a specific profile that needs to be analysed in greater depth. 

Similarly, a cross-sectional study conducted in Belgium (4) showed that BFHI accreditation improved rates of initiation of exclusive breastfeeding mainly in subgroups of mothers who were already more likely to breastfeed (particularly those with a university education). 

France has one of the lowest breastfeeding rates in Europe, with significant inequalities in different regions and in across socio-economic groups. Our study results show that BFHI-accredited maternity units do have a positive impact on the rate of exclusive breastfeeding. It also found a lower rate of mixed feeding compared with hospitals without accreditation. We have shown for the first time that this positive impact is even greater in low birth weight babies. Our work has shown that implementing the BFHI can improve breastfeeding practices in maternity units, with a particular focus on vulnerable groups, such as mothers of low birth weight babies, who tend to have lower breastfeeding rates.