摘要：Objectives. The Ten Steps to Successful Breastfeeding is a proven approach to support breastfeeding in maternity settings; however, scant literature exists on the relative impact and interpretation of each step on breastfeeding. We assessed the Ten Steps and their relationship with in-hospital breastfeeding rates at facilities serving low-wealth populations and explored the outcomes to identify step-specific actions. Methods. We present descriptive and nonparametric comparisons and qualitative findings to examine the relationship between the Ten Steps and breastfeeding rates from each hospital using baseline data collection. Results. Some steps (1-policy, 2-training, 4-skin-to-skin, 6-no supplements, and 9-no artificial nipples, followed by 3-prenatal counseling, 7-rooming-in) reflected differences in relative baseline breastfeeding rates between settings. Key informant interviews revealed misunderstanding of some steps. Conclusions. Self-appraisal may be less valid when not all elements of the criteria for evaluating Step implementation may be fully understood. Limited exposure and understanding may lead to self-appraisal errors, resulting in scores that are not reflective of actual practices. Nonetheless, the indication that breastfeeding rates may be better mirrored by a defined subset of steps may provide some constructive insight toward prioritizing implementation activities and simplifying assessment. These issues will be further explored in the next phase of this study. UNICEF and the World Health Organization (WHO), along with USAID and Swedish International Development Agency (SIDA), launched a comprehensive approach to protect, promote and support breastfeeding with the 1990 Innocenti Meeting and Declaration. 1 This document called for the implementation of Ten Steps to Successful Breastfeeding 2,3 to strengthen health care practices, along with calls for national committees, controls for formula marketing, and paid maternity leave. The Ten Steps have been shown to have a direct impact on breastfeeding rates at the hospital, national, and international level (see the box on the next page). 4–13 The Baby-Friendly Hospital Initiative (BFHI) was introduced in 1991 as a method to encourage national support and to recognize hospital-level adherence to all Ten Steps. Over the years, more than 22 000 health care facilities in more than 150 countries around the world have been designated “baby friendly” by global and national BFHI approaches, representing about 28% of all maternity facilities worldwide. 14a-b,15 Nonetheless, only about 5% of facilities in the United States are designated as baby friendly. Possible reasons for the slow progress in the United States include (1) the previously limited recognition by US health professionals and health professional organizations of the importance of breastfeeding, (2) assumptions by hospitals serving low-wealth and minority populations that their patients would not be interested in breastfeeding, (3) general lack of interest in this issue among hospital staff and administration, and (4) the complexity and costs of the US-based approach to designation provided by Breastfeeding Friendly USA (BFUSA), a nongovernment organization designed for this purpose. 16 To address the first and second of these concerns, the Carolina Global Breastfeeding Institute’s Breastfeeding-Friendly Healthcare project (CGBI/BFHC) was designed to support the Ten Steps in a set of hospitals located across North Carolina that serve low-income populations. 17 The overall purpose of this project is to increase breastfeeding initiation, exclusivity, and duration and reduce inequity in breastfeeding support by supporting hospitals to make improvements in the quality of breastfeeding support services by implementing the Ten Steps. CGBI/BFHC offered the opportunity to further explore the steps individually and as they relate to breastfeeding patterns.
