Master's Project Title:

The Design in Designation Program: Recognizing Breastfeeding Friendly Maternity Centers

MCH Student:

Virginia Johnson

Date of Defense:

April 1, 2016


Executive Summary


The first few days after delivery are crucial for mother-baby dyads to establish lactation and maintain breastfeeding. Unfortunately, many experience negative external influences during their maternity center stay, which undermine their breastfeeding intentions (Declercq E, 2009). There is a large gap between the percentage of women who initiate breastfeeding (81.9%) and women who achieve the WHO recommendation of six months of exclusive breastfeeding (25.5%) (CDC, 2014). Early cessation of breastfeeding has been associated with significant health risks for mothers and babies (Ip S, 2007). On a national level, up to $13 billion per year could be saved if 90% of women continued breastfeeding up to a year (Bartick M, 2010).

The WHO and UNICEF responded to this public health problem by launching the Baby-Friendly Hospital Initiative (BFHI), which aims to promote, protect and support breastfeeding within maternity centers (WHO, 2016). The 2011 US Surgeon General’s Call to Action to Support Breastfeeding encourages facilities to adopt the BFHI evidence-based guidelines, known as the Ten Steps to Successful Breastfeeding (Office of the Surgeon General, 2011). Implementing all of the Ten Steps has demonstrated the greatest impact on breastfeeding duration rates and on reducing racial/socioeconomic breastfeeding disparities (Taylor E, 2012). Achieving individual steps and sets of steps can also significantly impact breastfeeding rates (Nickel N, 2013).

More than 22,000 hospitals and birth centers in over 150 countries have become Baby-Friendly (Baby Friendly USA, 2016). Only 337 of those facilities are located in the US, which indicates that Baby-Friendly practices/policies are not normative, nor are they easily implemented in this country. Reported barriers to pursuing the Baby-Friendly designation include: resource scarcity, lack of collective cooperation, and complicated application process (Nickel N, 2013).


I worked with the Minnesota Department of Health (MDH) to design the MN Breastfeeding Friendly Maternity Center Designation (MN BFMCD) Program. The program recognizes facilities that have made progress toward implementing the Ten Steps: for every two steps achieved, they receive one star. The main learning objective of the field experience was to catalyze the ongoing program development by preparing a written design proposal. In determining the best program design, I compiled program materials from other state recognition programs. I achieved the objective by creating a program design that was compatible with the Baby-Friendly Pathway, complete with electronic application forms.

The second objective was to design program communication tools. I designed the program logo and all program materials (fact sheets, application instructions/forms, sample letters). I also provided the content and communicated the vision for the program website.

The third learning objective was to better understand how public health and medicine intersect to promote breastfeeding-friendly maternity center environments. I achieved this by reading scientific literature related to the impact of BFHI on breastfeeding outcomes. I also attended MN Breastfeeding Coalition meetings and the Perinatal Hospital Leadership Summit.

The fourth objective was to refine software skills in PDF editing. I learned how to create PDF forms in both Adobe Acrobat Pro and LiveCycle Designer, and how to efficiently export data from multiple application forms into an Excel database.

To meet the last objective of strengthening interpersonal and communication skills, I utilized multiple strategies to solicit input from stakeholders during the entire program development. I built relationships with diverse health professionals within state health departments, hospitals, and breastfeeding coalitions.


The mission of the MDH is “to protect, maintain and improve the health of all Minnesotans”. The state health department employees approximately 1500 people, of which 115 work under the Community and Family Health (CFH) Division (MDH, 2016). The CFH Division’s major focus is on policy, environmental and systems changes that improve health and reduce health care costs. One of its newest initiatives is to create Breastfeeding Recognition programs for health departments, child care centers, worksites and maternity centers. My field experience supported the overall mission of MDH by encouraging maternity centers to shape their policies and practices to better support breastfeeding mothers and babies.

Lessons Learned

MDH immediately launched the expedited application form and has already granted six awards during the end of my internship. However, nearly a year later, the full application has not launched. I have learned that working on a large-scale breastfeeding initiative with diverse partners is an enormous undertaking, which cannot be completed hastily.

Regarding the name of the program, some maternity centers expressed concern over using the term “Breastfeeding Friendly” because it conflicted with their all-inclusive, family-friendly policy. As the basis of the program was to improve breastfeeding, it seemed counter-intuitive to remove the term entirely. We compromised by creating a Minnesota Mother-Baby Ten STEPS Award, but kept the program title as is. It trained me to pay extra attention to certain program verbiage.


  • Develop a technical assistance webinar to explain the MN BFMCD application process.
  • Design a self-appraisal tool to help facilities evaluate readiness to apply for each step.
  • Create a guide with resources and strategies for implementing each of the ten steps, with an emphasis on the more difficult steps (Steps 1, 2, 4, and 6).
  • Evaluate the program by surveying maternity centers on: ease of applying; perceived benefits; and positive and negative experiences with implementing specific steps


Maternity centers play a pivotal role in creating an environment that promotes and supports breastfeeding. Implementing better policies and practices, by adopting more of the Ten Steps to Successful Breastfeeding, will improve breastfeeding outcomes and reduce health care costs.


Baby Friendly USA. (2016, March 1). Find Facilities. Retrieved from Baby Friendly USA:

Bartick M, e. a. (2010). The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis. Pediatrics(125), e1048–e1056.

CDC. (2014, July). Breastfeeding Report Card (United States). Retrieved March 14, 2016, from Division of Nutrition, Physical Activitiy and Obesity:

Declercq E, e. a. (2009). Hospital Practices and Women’s Likelihood of Fulfilling Their Intention to Exclusively Breastfeed. Am J Public Health.

Ip S, e. a. (2007). Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Evid Rep Technol Assess(153), 1-186.

MDH. (2016, February 10). Organizational Chart for MDH. Retrieved from Minnesota Department of Health Organizational Chart:

Nickel N, e. a. (2013). Applying Organisastion Theory to Understand Barriers and Facilitators to the Implementation of Baby-Friendly: A Multisite Qualitative Study. Midwifery(29), 956-964.

Nickel N, e. a. (2013). The Extent that Noncompliance with the Ten Steps to Successful Breastfeeding Influences Breastfeeding Duration. Journal of Human Lactation(29), 59-70.

Office of the Surgeon General. (2011). The Surgeon General’s Call to Action to Support Breastfeeding. Rockville (MD): Office of the Surgeon General (US). Retrieved from

Taylor E, e. a. (2012). Implementing the Ten Steps for Successful Breastfeeding in hospitals serving low-wealth patients. Am J Public Health(102(12)), 2262-8.

WHO. (2016). Baby-friendly Hospital Initiative. Retrieved from World Health Organization Nutrition Programs: