Longitudinal Analysis of Maternity Practices in Infant Nutrition and Care by Baby-Friendly Designation Status

Background/Objectives: Evidence-based maternity care practices are critical for supporting breastfeeding initiation, exclusivity, and continuation, and these practices are operationalized through the Baby-Friendly Hospital Initiative (BFHI) Ten Steps to Successful Breastfeeding. This study examined longitudinal trajectories of evidence-based maternity care practices by Baby-Friendly designation status among U.S. hospitals. Methods: Hospital-level data from the Centers for Disease Control and Prevention’s Maternity Practices in Infant Nutrition and Care (mPINC) surveys from 2018, 2020, 2022, and 2024 were analyzed. Hospitals completing at least two surveys were included in the analysis, categorized as having sustained designation, adopted designation late, lost designation, or never been designated. Longitudinal mixed-effects models estimated changes in total and domain-specific mPINC scores over time. Results: Among 2,304 hospitals, 400 sustained Baby-Friendly designation, 190 adopted designation late, 160 lost designation, and 1,554 were never designated. Hospitals with sustained designation maintained consistently high total mPINC scores from 2018 to 2024. Late adopters improved substantially, increasing 8.9 points (95% CI: 7.0,10.9), whereas hospitals that lost designation declined from 88.1 to 84.7, a change of −3.4 points (95% CI: −5.6, −1.3). Declines among hospitals that lost designation were most evident in immediate postpartum care, feeding practices, and institutional management domains. Never-designated hospitals’ scores improved modestly but remained below those of the sustained Baby-Friendly hospitals across survey years and domains. Conclusions: Sustained Baby-Friendly designation was associated with stable, high implementation of evidence-based maternity practices, whereas loss of designation was associated with measurable declines in key breastfeeding-supportive domains. Maintaining or regaining designation may protect equitable access to critical breastfeeding support services across communities.