Associations between breastfeeding and self-reported experience of the ‘10 Steps to Successful Breastfeeding’: a cross-sectional and longitudinal study of maternity clinic practices in Cyprus

Background Even though the beneficial effect of the Baby-Friendly Hospital Initiative’s (BFHI) 10 Steps on breastfeeding initiation, continuation and exclusivity is well established, implementation in maternity care services remains suboptimal. Objective To assess the implementation of the “10 Steps for Successful Breastfeeding” and explore associations with any Breastfeeding (BF) and Exclusive Breastfeeding (EBF) initiation and continuation. Methods Implementation of the 10 Steps was assessed on the basis of a consecutive sample of 568 mothers’ self-reported experience across all public (N = 5) and 29 (of 35) private maternity clinics using the WHO/UNICEF Baby Friendly Hospital Initiative questionnaire (Section 4) within the first 24–48 hours after birth. BF and EBF were estimated within 48 hours after birth as well as at 1st, 4th and 6th month based on a self-reported current status method. Associations with initiation and continuation of any (BF) and exclusive breastfeeding (EBF) up to the 6th month were explored in logistic regression after adjusting for potential confounders, including maternal breastfeeding self-efficacy. Associations were explored with individual steps as well as the overall experience, operationalized as the sum score of full, partial or no implementation of each self-assessment questionnaire item, with the exclusion of Step 6 (exclusivity). Results At mean score 6.2 (SD = 2.7), the overall 10 steps experience, was low (theoretical range 0–14), even among those who breastfed exclusively (M = 7.7, SD = 2.0). EBF and BF initiation and continuation showed a stepwise association with self-reported experience of the 10 steps. Across quartiles of increasing scores within 48 hours after birth, the prevalence of EBF was 7.5%, 14.4%, 19.0% and 34.2%. Mothers who experienced full or partial implementation of Step 4 (timely initiation with skin-to-skin) were more likely to initiate and continue BF and EBF up to the 4th month, while use of pacifiers was more likely to have an adverse effect on breastfeeding continuation and exclusivity. Conclusion The Baby Friendly hospital’s “10 Steps” are associated with BF initiation while certain practices seem to be more strongly associated with exclusivity and continuation of breastfeeding up to the sixth month While breastfeed intention may determine the actual experience of the 10 steps, this also suggests that maternity care practices can have a supportive role for mothers to succeed their intentions to BF and EBF. Certain practices appeared suboptimal across maternity clinics in Cyprus.