Breastfeeding, especially exclusive breastfeeding, is one of the most effective preventive health measures available to reduce infant morbidity and mortality. For all newborns, but especially for the sick ones, breastfeeding is a simple life saving method. To improve worldwide breastfeeding initiation and duration rates, the WHO and UNICEF launched the Baby-Friendly Hospital Initiative (BFHI) in 1991. The BFHI consists of the Ten Steps to Successful Breastfeeding and the WHO International Code of Marketing of Breast-milk Substitutes. The BFHI is currently the gold standard for evidence-based breastfeeding care in hospitals. Data continues to accumulate showing that adherence to the Ten Steps predict breastfeeding duration and exclusivity long after hospital discharge. However, despite the strong evidence for the Ten Steps, hospital compliance in Indonesia is poor. A national survey for hospitals in Indonesia in 2011 found only 8% of state hospital complying with 7 out of 10 steps of successful breastfeeding.

In order to improve hospital care for breastfeeding we need to identify the barriers and opportunities of BFHI Implementation in Indonesia and obtain solid local evidence on implementing of BFHI by performing a pilot project. Thus, this project will consist of 2 studies. Study 1 is a qualitative study exploring the barriers and facilitators of BFHI implementation in Indonesia. This study will cover various stakeholders related to hospital support for breastfeeding in Indonesia from all levels: Ministry of Health, Provincial and district health offices, related professional organization, several selected hospitals, and community mother support groups. Three provinces that will be involved are Jakarta, West Java, and Banten. One district will be selected for each province and three hospitals will be selected in the respective district. Study 2 is a quasi-experimental study which will be conducted in Banten Province involving 6 hospitals with different types of services and ownership that will be randomly allocated to intervention and control groups - 3 hospitals for each group. The intervention is WHO BFHI section 2 (training for hospital managers), WHO BFHI section 3 (training for maternity staff), and 12 months technical assistance performed by Indonesian Breastfeeding Center. The outcomes of this study are the performance of hospitals on BFHI implementation using WHO module, breastfeeding self efficacy scale, family breastfeeding support scale, LATCH score, and breastfeeding rates. These outcomes will be measured both for healthy and sick newborn.