Sir,In 1991, UNICEF and WHO launched the Baby?Friendly Hospital Initiative with the aim of increasing rates of breastfeeding. “Baby?Friendly” is a designation a maternity site can receive by demonstrating to external assessors compliance with the Ten Steps to Successful Breastfeeding. The Ten Steps are a series of best practice standards describing a pattern of care where commonly found practices harmful to breastfeeding are replaced with evidence based practices proven to increase breastfeeding outcome. Currently, approximately 19 250 hospitals worldwide have achieved Baby?Friendly status, less than 500 of which are found in industrialised nations. The Baby?Friendly initiative has increased breastfeeding rates, reduced complications, and improved mothers' health care experiences. There is a small, quiet revolution going on. An important indicator of good health appears to be rising faster in areas of social deprivation. This may not be unique, but it is certainly unusual. Breastfeeding, which has long been associated with the higher socioeconomic groups in industrialised countries, is now growing rapidly in some of the most socially deprived areas of the UK and USA.The Royal Oldham Hospital, for example, serves a deprived area to the north east of Manchester in the UK; nearly 30% of its clientele are non?English speakers. In 1994, the town demonstrated the low breastfeeding uptake common to most deprived areas: just 29% of mothers breastfed their babies at birth, and almost all switched to formula in the first 4 weeks. However, 5 years later, breastfeeding initiation had risen to 55% and has since continued to grow steadily, reaching 64% in 2005, while 40% of babies are now still being breastfed at 4 weeks (Val Finigan, Infant Feeding Coordinator, Royal Oldham Hospital, personal correspondence, 27 June 2005).This dramatic improvement was achieved against a background of unchanging national breastfeeding rates. Data from the quinquennial national infant feeding surveys show no significant increases in English or UK breastfeeding rates since 1980. An exception to this pattern can be found in Scotland, which was the only part of the UK to record a significant increase in breastfeeding duration rates in 2000, with rising prevalence found at all ages up to 9 months.The difference in Oldham was the hospital trust's far?sighted decision in 1994 to implement the best practice standards necessary for accreditation as Baby?Friendly by UNICEF and the World Health Organization. Scotland's achievement is due to the adoption of breastfeeding strategies by the country's health boards, with Baby?Friendly accreditation as a central component: more than half of Scottish babies are now born in Baby?Friendly hospitals, compared with just 8.6% in England. A similar picture is emerging in the USA. Boston Medical Center (BMC) is an academic teaching hospital, serving primarily minority, poor, and immigrant families living in inner city Boston, MA. In 1997, a group of clinicians concerned about BMC's low breastfeeding rates launched a breastfeeding initiative, which culminated in December 1999 when BMC became the 22nd Baby?Friendly hospital in the USA. Prior to implementation of Baby?Friendly policies, breastfeeding rates at BMC were unimpressive. Leaders of the breastfeeding initiative were aware that impoverished and African American women traditionally had low breastfeeding rates. However, they were more concerned that non?supportive hospital policies and lack of support from health care staff were creating barriers to breastfeeding. They wondered if the problem “was us, not them”. One thing they knew for certain was that every woman wants the best for her baby. Their mission became to create an institution which promotes and supports breastfeeding and see if greater numbers of women would breastfeed, irrelevant of their social status or racial group.For three challenging years they tore up antiquated policies, said “no thank you” to free formula
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