Baby-Friendly e-Newsletter : Baby Friendly Watch (Jul 2026)

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Date: 2026-07-22

For the latest updates on the Baby-Friendly Health Facilities Designation Programme, including the dates on which hospitals and Maternal and Child Health Centres (MCHCs) achieved different designation levels, please visit: https://www.babyfriendly.org.hk/en/healthcare-facilities

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Discover how Hong Kong is advancing the Baby-Friendly Hospital Initiative (BFHI) by transitioning from the 2009 to the 2018 WHO/UNICEF guidance. This article highlights the shift from an accreditation-focused approach to a continuous quality improvement framework, the progress made by Baby-Friendly hospitals in strengthening breastfeeding support and maternity care practices, and the key areas requiring further enhancement—including NICU skin-to-skin care, breastfeeding support for separated mothers and babies, and exclusive breastfeeding outcomes. Learn why breastfeeding remains a public health priority and how coordinated efforts across healthcare systems, government, workplaces, and communities are essential to support families and improve maternal and newborn health.

Please click here to download the PDF version of the whole article with images and the references. The preview is at the bottom of this webpage.

Moving the BFHI from 2009 to 2018:

The Progress in Hong Kong

Ms LAM Chi-oi, Christine

APN, Hong Kong Breast Milk Bank,

Chairperson of Committee on Designation of Baby Friendly Health Facilities, BFHIHKA

The Baby-Friendly Hospital Initiative (BFHI), launched by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) in 1991, has long served as a global strategy to protect, promote, and support breastfeeding. The initiative was built upon the “Ten Steps to Successful Breastfeeding,” designed to improve breastfeeding outcomes and maternal-infant care practices worldwide. In 2009, the BFHI package represented an important modernisation of earlier guidance. Between 2015 and 2018, WHO and UNICEF undertook a comprehensive reassessment of BFHI. They concluded that the initiative needed to move beyond a hospital accreditation programme towards a broader quality-improvement framework integrated into health systems and routine maternity care. By 2018, the revised implementation guidance was launched to improve sustainability, expand coverage, strengthen accountability, and align the BFHI with evolving evidence-based maternal and newborn care practices.

The transition from the 2009 to the 2018 BFHI guidance marked a major strategic shift. While the Ten Steps remained central, the revised guidance emphasised continuous quality improvement, reinforced compliance with the International Code of Marketing of Breast-milk Substitutes and expanded the scope of care to include vulnerable newborn populations and ensure long-term sustainability. The 2018 revision positioned the BFHI not simply as a hospital initiative, but a comprehensive framework for improving maternal and newborn care worldwide.

The revised version distinguishes between organisational accountability and clinical bed-side support, moving the standards towards clinical competency and informed choice. Rather than focusing primarily on accreditation, the new guidance emphasises:

Strict protection from commercial influence
Universal implementation of the Ten Steps
Continuous quality improvement
Integration into national policies and standards
Sustainability through health-system ownership
Accountability and monitoring

The State of Implementation in Hong Kong

In Hong Kong, the BFHI accreditation process only started in the early 2010s. The first hospital began its application in 2013 and was successfully designated BFH in 2016. This was followed by all public hospitals completing the process in 2023 and one private hospital in 2024. After the introduction of the 2018 BFHI guidance, accredited Baby-Friendly hospitals have made strides in transforming their infant feeding policies and practices using the new standards. The Baby-Friendly Hospital Initiative Hong Kong Association (BFHIHKA) officially transitioned to the revised 2018 standards for hospital revalidations from 2024.

Since the implementation of the 2018 assessment criteria, 8 public hospitals have undergone BFH revalidation, with the majority achieving the required ≥80% compliance benchmark. All participating hospitals have demonstrated strong compliance with the International Code of Marketing of Breastmilk Substitutes, while 7 hospitals have revised their breastfeeding policies to align with the 2018 BFHI standards. The structured antenatal discussion protocols used by nurses to discuss the importance and management of breastfeeding with pregnant women and families have been updated. Implementation of practices to promote uninterrupted mother-infant contact through 24-hour rooming-in and support mothers to recognise and respond appropriately to infant feeding cues have been in place consistently. Moreover, counselling on the appropriate use of and potential risks associated with feeding bottles, teats, and pacifiers, together with coordinated discharge planning to facilitate timely access to ongoing breastfeeding support and postnatal care, have been effectively integrated into routine clinical practice.

Notwithstanding these achievements, several clinical, operational and administrative domains have remained below the global 80% compliance benchmark, highlighting priority areas requiring targeted quality improvement interventions. The following table shows the steps that have failed to meet the standards and require further enhancement.

(For Table 1 – BFHI Ten Steps (2018 Version): Compliance Status and Required Actions: please refer to the PDF version )

Other Strategic Recommendations for Care Improvement

Achieving these standards requires a hospital-wide commitment, underpinned by strong administrative and clinical leadership. This includes supporting practice change, allocating protected time for staff education and competency assessment, and ensuring the necessary infrastructure is in place.
Structural modifications are essential, such as optimising postnatal ward layouts to facilitate rooming-in and redesigning NICU environments to enable safe, comfortable, and sustained parent-infant skin-to-skin contact.
Staff knowledge and clinical competencies in breastfeeding management should be further strengthened, particularly in the assessment and management of early breast complications, neonatal jaundice, and the delivery of effective breastfeeding support.
Staff education must shift from passive classroom training to direct, bedside clinical skill evaluations. This should be reinforced through systematic documentation, regular internal audits, and targeted competency assessments.
Implementing an automated internal data management and alert system would enable continuous monitoring of key clinical indicators, with particular attention to two sentinel measures: immediate and uninterrupted skin-to-skin contact following birth, and exclusive breastfeeding.

Breastfeeding as a Public Health Priority in Hong Kong

Hong Kong is facing a worrying decline in overall breastfeeding rates, with persistently low levels of exclusive breastfeeding sustained through the recommended first six months of life. While the Baby-Friendly Hospital Initiative (BFHI) provides a robust institutional framework for promoting, protecting, and supporting breastfeeding within healthcare facilities, lasting success cannot rely solely on hospital-based interventions or healthcare professionals.

Breastfeeding should be recognised not as an isolated healthcare initiative, but a broader public health priority that extends well beyond the clinical setting. Reversing the current downward trend will require strong government commitment and leadership, alongside partnerships across all sectors of society. Sustained, system-wide efforts must address public education, the regulation of marketing of breastmilk substitutes, workplace and community support, and family-friendly environments in public spaces, complementing the support already provided within healthcare facilities.

References

Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-friendly Hospital Initiative. WHO & UNICEF, 2018. https://www.who.int/publications/i/item/9789241513807.
Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: the Baby-friendly Hospital Initiative: monitoring manual. WHO & UNICEF, 2025. https://www.who.int/publications/i/item/9789240103764.
Reports on annual survey. The Baby Friendly Hospital Initiative Hong Kong Association. https://www.babyfriendly.org.hk/en/reports-annual-survey/.

Editor-in-Chief: Dr Shirley Leung

Editorial Team: Mrs Francis Au, Ms Sally Wan, Ms Sing Chu, Dr Annie Fok, Ms Ivy Yiu, Ms Julia Yeung, Dr Ana Lee, Ms Tracy Ling, Ms Wong Ka Yin, Ms Lo Ka Yee

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