Effectiveness of Baby-Friendly Hospital Initiative on Early Initiation and Exclusive Breastfeeding Practice: Systematic Review and Meta-Analysis

Abstract

Background: The Baby-Friendly Hospital Initiative (BFHI) promotes, protects, and supports optimal breastfeeding through facility-based strategies. While prior studies have examined individual BFHI components in specific contexts, global evidence on its overall impact remains limited. This systematic review and meta-analysis aimed to evaluate the BFHI's effectiveness in improving early initiation and exclusive breastfeeding practices worldwide. Methods: A comprehensive search was conducted in PubMed, Web of Science, Scopus, and Google for English-language studies. Eligible studies included randomized controlled trials (RCTs), cluster RCTs, and quasi-experimental designs assessing BFHI's effect on breastfeeding outcomes. Random-effects meta-analysis models were used to estimate the pooled effects with 95% confidence intervals (CI). Heterogeneity was assessed using I2 statistics and p-values. Study quality was appraised using the GRADE approach. Results: Thirty studies met the inclusion criteria. The BFHI was associated with increased early initiation of breastfeeding (pooled RR 1.43; 95% CI: 1.12-1.81; I2 = 97.1%). Positive associations were also observed for exclusive breastfeeding at four months (RR 1.18, 95% CI: 1.08-1.29; I2 = 61.7%) and at six months (RR 1.56, 95% CI: 1.14-2.14; I2 = 82.8%). Substantial heterogeneity reflected variability in study design, BFHI implementation fidelity, and context. Conclusions: Our findings suggest that the BFHI is effective in improving breastfeeding practices globally. However, study variability and partial implementation may limit the generalizability of results. High-quality RCTs assessing full BFHI implementation are needed to strengthen evidence and guide global maternal-child health policy.