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The Connecticut Breastfeeding Initiative (CBI) is a PSE Change intervention designed to promote practices in maternity facilities that support the initiation and continuation of breastfeeding. The Ten Steps to Successful Breastfeeding provide the foundation of the Baby-Friendly Hospital Initiative (BFHI). The Steps focus on breastfeeding initiation, exclusive breastfeeding, skin-to-skin contact, and rooming in, among other elements. By providing a state-level support system of training, technical assistance, and financial assistance, the CBI assisted multiple hospitals in progressing down the 4-D Pathway with the intention of becoming Baby-Friendly designated. The cornerstone of the CBI is the implementation of the Baby-Friendly Hospital Initiative (BFHI) at the hospital level.

NOTE: Portions of this initiative may be SNAP-Ed appropriate. Should be done in collaboration with WIC and other maternal and child health programs.

Intervention Target Behavior: Pregnant/Breastfeeding

Snap-Ed Strategies: PSE Change

Intervention Reach and Adoption

The CBI's reach to multiple subgroups was comparable to that reported by all hospitals in Connecticut. The table below shows the statewide proportions on several child/mother health indicators as compared to those for the ten CBI hospitals. Public pay birth (Medicaid-paid delivery) proportions, as an indicator of promoting equitable access to BFHI resources among low-income women, are also included. Of the ten CBI hospitals, seven reach a primarily urban population and three reach a primarily rural population.

 % Statewide (of all births in the State*)% among CBI hospitals (n=10)
Medicaid-paid delivery76.6%78.6%
Birthweight (very Low or low)8.6%8.4%
Maternal age16.0%16.1%
Births by race/ethnicity 

*Includes births that occurred at 29 acute care hospitals, one birthing center, and at home.

Settings: Healthcare

Age/Population Group: Pregnant/Breastfeeding

Race: All

Ethnicity: All

Intervention Components

The CBI's main intervention components include:

  • Offering each participating hospital up to 40 hours of consultation time,
  • Providing the 15-lesson training (as identified by Baby-Friendly USA) for maternity staff and offering guidance to participating hospitals on the five competency hours (clinical experience),
  • Recommending appropriate strategies for completing the three Continuing Medical Education (CMEs) hours for MDs,
  • Contributing $750 per hospital to disseminate patient and staff education materials,
  • Providing financial support for Baby-Friendly USA maternity hospital fees ($4,000 per CBI hospital), and
  • Coordinating monthly conference calls and bi-monthly in-person workshops for key hospital contacts for purposes of collaboration and peer support.
Intervention Materials

The materials supporting this intervention have been carefully developed by the Connecticut Department of Public Health and the Connecticut Breastfeeding Coalition. They are meant to serve as example documents, not exact guidelines for successful intervention replication.

  • Toolkit cover letter. Provides guidance on what to include in a toolkit at the beginning of an initiative like the CBI. (The content of the toolkit is not available as it contains proprietary information.)
  • CBI Hospital Assessment Form. This is the assessment form the CBI used to select hospitals for participation in the Baby-Friendly project.
  • Baby-Friendly USA Designation Process. This guidance document is from Baby-Friendly USA and discusses the 4-D Pathway to Baby-Friendly Designation:
  • Sample Baby-Friendly USA Self-Appraisal. Please contact Baby-Friendly USA for information about the Self-Appraisal tool. Sample tool available on Baby-Friendly USA website:


Evidence Summary

The evidence summary provided below is based on the evaluation report compiled by Professional Data Analysts.

Hospital Level 4-D Pathway and Practice changes: All 10 hospitals achieved Steps 1, 5, 6, 9 and 10 of the Ten Steps of the Baby-Friendly process, and all were working on achieving the remaining steps. At baseline, one hospital had begun the BFHI journey through the Certificate of Intent process (this process was not associated with any Phases, just completion of the Ten Steps and fair market purchasing of infant formula). The remaining nine hospitals were not yet on the BFHI journey, but entered Discovery (the first Phase of the 4-D Pathway) as part of CBI. At the conclusion of the CBI project, the Certificate of Intent hospital had achieved Baby-Friendly designation. At the end of the project period, one of the remaining nine hospitals was in the Development Phase, seven of the nine were in the Dissemination Phase, and one was in the Designation Phase.

Maternity staff training outcomes:

  • Hospitals reported that 583 individuals had been trained in some way (either by the CBI consultant, a person at his/her hospital, or online) and were eligible to complete the maternity staff survey.
  • Of those individuals who received training, 230 completed the survey and were included in the analysis.
  • These respondents received all 15 lessons through one method or a mix of methods.

The retrospective, one-time survey asked respondents about the extent to which they performed the Baby-Friendly practices before and after the Baby-Friendly training. Practice changes among survey respondents are reported in Figure 1, and confidence levels in Baby-Friendly practices among survey respondents are reported in Figure 2. Figure 1 below shows the percentage point increase in respondents who strongly agree or agree that they perform the Baby-Friendly practices, as reported after the 15-hour training. The percentages of maternity staff reporting strong agreement or agreement on the practice before and after are reported in parentheses, while the percentage point increase is shown by the bar on the right.

Figure 1. Percentage point increase in respondents who strongly agree or agree that they performed Baby-Friendly practices before as compared to after the 15-hour training.

Baby-friendly practice

Figure 1 Content in Text-only Format:

Baby friendly practices of maternity staff represented in percentages before and after the 15-hour training as well as overall change of percentage points

1. Facilitate skin to skin within 5 minutes. Before: 67.7%. After: 95%  Change of 27.3 percentage points.

2. Routinely refer to breastfeeding support groups. Before: 71.4% After: 92.3%. Change of 20.9 percentage points.

3. Know what to say if asked to put baby in nursery. Before: 80.2% After: 98.9%  Change of 18.7 percentage points.

4. Willing to conduct procedures at bedside. Before: 79.2% After: 95.3%  Change of 16.1 percentage points.

5. Explain why not to give pacifiers. Before: 79.2% After: 95.0%  Change of 15.8 percentage points.

6. Encourage rooming-in. Before: 82.0% After: 97.2%  Change of 15.2 percentage points.

7. Provide resources to families. Before: 84.3% After: 98.3%  Change of 14.0 percentage points.

8. Don't restrict frequency/length of feeding. Before: 85.7% After: 97.8%  Change of 12.1 percentage points.

9. Only promote breast milk. Before: 87.9% After: 98.3%  Change of 10.4 percentage points.

10. Teach how to latch and position. Before: 91.6% After: 99.5%  Change of 7.9 percentage points.

11. Can access and refer to breastfeeding policy. Before: 90.1% After: 97.8%  Change of 7.7 percentage points.

12. Help breastfeeding initiation within 1 hour. Before: 89.3% After: 94.8%  Change of 5.5 percentage points.

13. Advise to breastfeed when baby is hungry. Before: 93.6% After: 98.9%  Change of 5.3 percentage points.

14. Educate on feeding cues. Before: 97.4% After: 99.5%  Change of 2.1 percentage points.

15. Offer breastfeeding assistance within 6 hours. Before: 97.1% After: 98.2%  Change of 1.1 percentage points.

16. Provide information about breastfeeding benefits. Before: 98.5% After: 99.5% Change of 1.0 percentage points.

Figure 2 below shows the percentage of trained maternity staff who are reported being somewhat or very confident in their ability to perform the Baby-Friendly practice. As shown in figure 2, at the conclusion of the initiative, nearly all respondents were somewhat or very confident that they could explain the advantages of breastfeeding for mother and baby and educate a mother on the relationship between skin to skin and breastfeeding initiation, and that they understood the role of the hospital lactation consultant.

Figure 2. Percent of trained maternity staff that are very or somewhat confident in their ability to perform the Baby-Friendly practice.

Staff Confidence to perform baby friendly practice

Figure 2 Content in Text-only Format:

Percent of trained maternity staff that are very or somewhat confident in their ability to perform the Baby-Friendly practice.

I can explain the advantages of breastfeeding for both mother and baby.  Very confident: 87.9%  Somewhat confident: 12.1%

I can educate a mother on the relationship between skin to skin and breastfeeding initiation.  Very confident: 87.8%  Somewhat confident: 12.2%

I understand the role of our hospital's LC.  Very confident: 83.3%  Somewhat confident: 14.4%

I have a clear understanding of the few medical reasons for prescribing food or drink other than breast milk for babies.  Very confident: 82.6%  Somewhat confident: 16.9%

I can provide reasons for not using breast milk substitutes, artificial nipples, and pacifiers.  Very confident: 81.9%  Somewhat confident: 17.5%

I can educate a patient on the relationship between rooming-in and breastfeeding exclusivity.  Very confident: 80.2%  Somewhat confident: 19.8%

I can help a family calm their baby without the use of a pacifier.  Very confident: 78.0%  Somewhat confident: 21.4%

I can discuss my hospital's policy to protect, promote, and support breastfeeding.  Very confident: 77.9%  Somewhat confident: 19.8%

I can quickly respond to a mother's request to send her baby to the nursery by discussing the benefits of...  Very confident: 75.9%  Somewhat confident: 22.4%

I can help a frustrated mother with early breast problems such as sore/cracked nipples and engorgement.  Very confident: 73.7%  Somewhat confident: 22.8%

Hospitals do collect data on breastfeeding initiation and exclusivity; however, these data were not part of the evaluation report that was reviewed.

Evidence Base: Practice-tested

Evaluation Indicators

Based on the SNAP-Ed Evaluation Framework, the following outcome indicators can be used to evaluate intervention progress and success.

 Readiness and Capacity - Short Term (ST)Changes - Medium Term (MT)Effectiveness and Maintenance - Long Term (LT)Population Results (R)
Environmental Settings MT5LT5, LT7
Sectors of Influence   
Evaluation Materials

The CBI project evaluators created several materials for its evaluation. Please provide credit to the Connecticut Department of Public Health and the Connecticut Breastfeeding Coalition, when reproducing materials in the original, or adapted, form:

  • CBI Hospital Breastfeeding Committee Face Sheet - Describes the methods, protocol, and rationale for interviews with each hospital's breastfeeding committee or representatives.
  • CBI Hospital Breastfeeding Committee Interview Questions - Provides the script and interview guide for interviews with the hospitals' breastfeeding committees.
  • CBI Maternity Staff Web Survey - Provides the rationale for and introduction to the survey, along with the survey questions.


Additional Information

Contact Person(s):

Department of Public Health:

Marilyn Lonczak, State Breastfeeding Coordinator

Department of Public Health

Connecticut WIC Program

Phone: (860) 509-8084


Connecticut Breastfeeding Coalition (CBC):

Monica Belyea, Board Member




*Updated as of October 4, 2023

Resource Type
Age/Population Group
Intervention Target Behavior
Evaluation Framework Indicators
SNAP-Ed Strategies
Evidence Base