Social Value of Baby-Friendly Hospital Initiative Implementation in Australia: Case Study

Social Value of Baby-Friendly Hospital Initiative Implementation in Australia: Case Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Social Value of Baby-Friendly Hospital Initiative Implementation in Australia: Case Study Andini Pramono, Julie Smith, Jane Desborough, Siobhan Bourke This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-97226/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Jan, 2021 Read the published version in International Journal for Equity in Health → Version 1 posted 10 You are reading this latest preprint version Abstract Background Breastfeeding has positive impacts on the health, environment, and economic wealth of families and countries. Nevertheless, barriers to accessing high-quality breastfeeding support are evident in the low global exclusive breastfeeding rate of 41%. The World Health Organization (WHO) launched the Baby Friendly Hospital Initiative (BFHI) in 1991 as a global program to incentivize maternity services to implement the Ten Steps to Successful Breastfeeding (Ten Steps). These were developed to ensure that maternity services remove barriers for mothers and families to successfully initiate breastfeeding and to continue breastfeeding through referral to community support after hospital discharge. However, in 2020 only 26% of Australian hospitals were BFHI-accredited. This study aimed to examine the social return on investment (SROI) of implementing the BFHI in one public maternity unit in Australia. Method The study was non-experimental and conducted in the maternity unit of an Australian BFHI-accredited public hospital with around 1000 births annually. This facility illustrated costs for BFHI implementation in a relatively affluent urban population, and more than three in four births in Australia take place in public hospitals. Stakeholders considered within scope of the study were the mother-baby dyad and the maternity facility. We interviewed the hospital’s Director of Maternity Services and the Clinical Midwifery Educator, guided by a structured questionnaire, which examined the cost (financial, time and other resources) and benefits of each of the Ten Steps. Analysis was informed by the Social Return on Investment (SROI) framework, which uses monetary values to measure social, environmental and economic outcomes of change. This information was supplemented with micro costing studies from the literature that measure the benefits of the BFHI. Results The social return from the BFHI initiative in this facility was calculated to be AU$ 1,398,140. The total investment required was AU$ 24,433 per year. Therefore, the SROI ratio was approximately AU$ 55:1 (sensitivity analysis: AU$ 16-112), which meant that every AU$1 invested in BFHI implementation by this maternal and newborn care facility generated approximately AU$55 of benefit. Conclusions Scaled up nationally, the BFHI could provide important benefits to the Australian health system and national economy. In this public hospital, the BFHI produced social value greater than the cost of investment, providing new evidence of its effectiveness and economic gains as a public health intervention. Our findings using a novel tool to calculate the social rate of return, indicate that implementation of the BHFI is an investment in the health and wellbeing of families, communities and the Australian economy, as well as in health equity. Health Policy Social Value Breastfeeding Investment (SROI) World Health Organization (WHO) Background Breastfeeding is the normal biological standard of infant feeding. It has benefits to infant and maternal health, and reduces health inequality, as well as reducing harmful impacts to the environment and decreasing health expenditure attributed to preventable illness. Socioeconomic groups with lower education and income levels are less likely to breastfeed when compared to their higher education and income group peers (1). Children who are not breastfed have, inter alia, higher rates of obesity, malocclusion and asthma, and lower intelligence quotients (2), while a lack of breastfeeding increases maternal risk of ovarian cancer, breast cancer, type 2 diabetes and osteoporosis (3, 4). The World Health Organization (WHO) recommends breastfeeding exclusively for the first six months of infants’ life (5). Despite the benefits, the exclusive breastfeeding rate globally is only 41% (6). High-income countries such as Australia have shorter breastfeeding duration than low- and middle-income countries, even though breastfeeding has been proven to reduce the risk of sudden infant deaths by more than one third in high-income countries and half of all diarrhea episodes and a third of respiratory infections in low and middle-income countries (7). Factors associated to low breastfeeding initiation and/or duration include maternal and paternal lower education (8, 9), partners’ negative attitudes towards breastfeeding (10), mother/baby separation after birth (9) and lack of health professionals’ knowledge of breastfeeding (11, 12). The first few hours and days of an infant’s life are critical to establish breastfeeding. Therefore, WHO launched Ten Steps to Successful Breastfeeding in 1989 and Baby Friendly Hospital Initiative (BFHI) in 1991 to focus on providing a high standard of maternity services to enable every infant to attain the best nutrition standards available. In 2018, WHO revised the Ten Steps (13). The revisions are subtle, but meaningful for implementation, with the focus shifted from healthcare staff to parents and families, empowering and enabling women and families to make choices regarding infant feeding method based on information free from conflict of interest (14). BFHI status is awarded to hospitals that implement high quality maternity care through the Ten Steps to Successful Breastfeeding policy; while remaining independent from formula companies and their affiliates (15), and re-assessed every three years (16). UNICEF Australia passed governance of BFHI within Australia to Australian College of Midwives (16). In 2006, the Australian Baby Friendly Hospital Initiative became the Baby Friendly Health Initiative in order to more accurately reflect the expansion of the initiative into community health facilities (16). Implementing the Ten Steps and achieving BFHI accreditation is essential to ensure quality of maternity care received by mothers and families, regardless of their social, economic, race and religious background. The benefits of implementing Ten Steps and achieving BFHI accreditation and its impact on breastfeeding has been demonstrated in research internationally (17-21), and the cost-effectiveness of BFHI in reducing late neonatal infant mortality rate has been established (22). Despite evidence that the BFHI improves the wellbeing of mothers and significantly increases the duration of breastfeeding (17), only 10% of births occur in maternity services that are designated as baby-friendly internationally (23), and only 77 out of 266 maternity services (26%) in Australia are baby-friendly accredited as of 2020 (24). Several Australian studies showed barriers to BFHI implementation that are similar to those described internationally (25), such as lack of policy support and funding due to the low priority and value of breastfeeding (26, 27). One Australian study showed that perception that the cost of BFHI accreditation may outweigh the benefit which could hinder the scale up of the BFHI program in Australia (28). No studies have explored the social return on investment of the BFHI in the Australian context. Research aim/question This study aimed to examine the social return on investment (SROI) of implementing the BFHI in one public maternity unit in Australia. Methods Sample and location The study was conducted in an Australian BFHI-accredited public hospital in August 2019. We selected this hospital because three in four Australian mothers give birth in public hospital (29) and this particular hospital has been BFHI-friendly accredited for 15 years. Data collection Interviews aimed to elucidate the costs of implementing the BFHI. Underpinned by the principles of the Social Return on Investment (SROI) framework, and in collaboration with the Director of Midwifery, the Clinical Midwife Consultant, and the Clinical Midwifery Educator, we developed a structured questionnaire based on the 2018 Ten Steps to Successful Breastfeeding (Ten Steps) which was used for the interview. The interview was conducted on 21 st August 2019 and took one and a half hours. Data storage The interview was audio-recorded and then transcribed verbatim. Data was stored on password protected computer at the university and only accessible to the primary researcher. Data analysis Data was analyzed in excel using the SROI framework, which uses monetary values to measure social, environmental and economic outcomes of change. The SROI is a framework for measuring and accounting for the much broader concept of value; it seeks to reduce inequality and environmental degradation, and improve wellbeing by incorporating social, environmental and economic costs and benefits (30). The benefits of breastfeeding are associated with a wide range of outcomes including health and social benefits. Therefore, the SROI methodology was relevant to help understand the value created by these programs to inform policy making. The information obtained in the interviews was supplemented with evidence-based estimations from the literature that measured the benefits of the BFHI. SROI analysis involves a 5-step process: establishing scope and involving stakeholders, mapping outcomes, evidencing and valuing outcomes, establishing impact, and calculating the SROI ratio. Each step is explained in detail below. Establishing scope and involving stakeholders First, we identified the stakeholders for SROI analysis. For our analysis, implementation of the Ten Steps as a framework for the BFHI involved two main stakeholders: the mother and baby dyad, and the maternity facility. These two main stakeholders were included as they were identified to derive the greatest benefits from Ten Steps implementation and sufficient evidence was available, and it was feasible to measure and include. Mapping outcomes Second, we mapped the outcomes for each stakeholder. A theory of change was developed from the literature, representing how the BHFI were expected to bring about change. For mothers, the benefits included risk reduction of breast cancer, cardiovascular disease, ovarian cancer, hypertension, and for no cost related to buying formula (3, 31-35). For babies, the benefits include reduced risk of diarrhea, respiratory infection, acute otitis media, necrotizing enterocolitis, obesity, Sudden Infant Death Syndrome (SIDS) diabetes, and higher IQ (2, 36-45). Evidencing and valuing outcomes Third, we searched the literature to evidence outcomes (Table 1). The cost in achieving BFHI accreditation based on interview findings (see Appendix 1). From the interview, costs relating to the BFHI application fee, lunch cost for the assessors, human resource relating to the cost of policy revision, BFHI system monitoring and compliance, breastfeeding counseling, staff training, as well as printing and laminating cost, provision of breastfeeding tools (e.g. nipple shield, pill-cups for cup feeding, hospital-grade breast-pump) and formula purchase for special-needs, preterm and low birth weight babies. Table 1. Financial proxy used to allocate a market price Babies Financial proxy Cost Reduce risk of diarrhea Cost of gastrointestinal (46) AUD 20.27 Reduce risk of respiratory infection Cost of influenza-related disease (47) AUD 2,864 Reduce risk of acute otitis media Cost of treating otitis media in Australia (48) AUD 594 Reduce risk of necrotizing enterocolitis Cost of NEC treatment (49) AUD 13,863 Higher IQ Annual earnings (average weekly income in Australia (50) x 52 weeks)* AUD 89,487 Reduce risk of obesity Cost of obesity in Australia (51) AUD 2,500 Reduce risk of type 1 diabetes Cost of diabetes in Australia (52) AUD 3,131 Reduce risk of type 2 diabetes Reduce risk of Sudden Infant Death Syndrome (SIDS) Annual earnings (average weekly income in Australia (50) x 52 weeks)* AUD 89,487 Mothers Reduce risk of breast cancer Cost of breast cancer treatment per case in Australia (53) AUD 36,448 Reduce risk of cardiovascular disease Cost of cardiovascular disease treatment in hospital in Australia (54) AUD 1,700 Not buying formula Formula supply for one year for full formula-fed baby (1.5 tins for a week for the first 6 months and 0.6 tin for a week for the next 6 months) * We followed WHO guidance (55) and adapt it to Australian settings AUD 1,160 Reduce risk of ovarian cancer Cost of ovarian cancer treatment per person in Australia (53) AUD 31,958 Reduce risk of hypertension Cost of hypertension treatment per diagnosed case (54) AUD 570 *assumption Establishing Impact Deadweight, attribution, and displacement were subtracted from the outcome to reduce the risk of over-claiming benefits. To determine the specific value, we reviewed the literature on breastfeeding. Deadweight relates to a change that would have happened anyway even if BFHI was not implemented; we assumed that 5% of benefits would have happened without the BFHI. Displacement is an assessment of how much of the outcome displaced other outcomes; we assumed the BFHI would displace 20% of other activity. Attribution is the term used for change that occurred caused by other intervention; we assumed 25% of benefits were attributed to other activities. We also assumed that 20% of the benefits would decline (drop off) over time. Calculating the SROI and sensitivity analysis In this step we estimated how long the outcomes will last and used them in the analysis. Here we knew the duration of the outcome due to earlier literature search and interviews. We assumed the benefit included the risk reduction of diarrhea, respiratory infection, acute otitis media and necrotizing enterocolitis lasted for three years; higher IQ, risk reduction of obesity, type 1 and type 2 diabetes and SIDS for 30 years; risk reduction of breast and ovarian cancer, hypertension and cardiovascular disease for 15 years; and formula supply for two years. The costs and benefits were discounted to calculate the net present value, to ensure that the costs and benefits in different time periods were comparable. The recommended rate of 4% (56) was used, recognizing the value of cash today is higher than value of cash in the future. This is the net present value (NPV). After the net present value was calculated, we subtracted the investment and then divided it by the total input, that being the total monetary investment in the BHFI. We conducted a sensitivity analysis identifying the estimated with the greatest impact on the SROI ratio, to test how sensitive the ratio is to changes in these estimates including in the deadweight, displacement and attrition and specific estimates. Results The average number of births in Calvary public hospital was 1000 annually, with exclusive breastfeeding rate on discharge of 97% in 2019. The value of benefits and costs is summarized in Table 2. Table 2: Value of benefits and costs of BFHI accreditation at Calvary Public Hospital Benefits Annual amount in AUD Babies Reduce risk of diarrhea 3,004 Reduce risk of respiratory infection 41,138 Reduce risk of acute otitis media 36,397 Reduce risk of necrotizing enterocolitis 100,591 Higher IQ 9 Reduce risk of obesity 276,832 Reduce risk of type 1 diabetes 118 Reduce risk of type 2 diabetes 33,106 Reduce risk of Sudden Infant Death Syndrome (SIDS) 612,091 Mothers Reduce risk of breast cancer 111,668 Reduce risk of cardiovascular disease 4,186 Not buying formula 121,859 Reduce risk of ovarian cancer 52,462 Reduce risk of hypertension 4,679 Total value of benefits 1,398,140 Investments Total value of investments 24,433.80 Net Yield (benefits less investments) 1,373,705.73 Social Return on Investment (SROI) 55.38 The social return (benefits) was calculated to be AU$ 1,398,140 and total investment required was AU$ 24,433 per year. Therefore, the SROI ratio was 55:1, which meant that every AU$ 1 invested in the BFHI generated approximately AU$55 of benefit to the Australian economy. The payback period was 0.63 month, which meant that all the investment would return in around 1 month. For our baseline estimation of the SROI we used conservative assumptions. We conducted sensitivity analysis by trying different assumptions (table 3). The SROI calculation was dominated by the high value of risk reduction in obesity and SIDS for babies as well as breast cancer risk reduction for mothers. Table 3: Base and new case scenarios Sensitivity analysis Base case New case New ratio Attribution 25% 50% AU$ 37 Deadweight 5% 50% AU$ 29 Displacement 20% 0% AU$ 69 Drop off 20% 50% AU$ 16 Discount rate 4% 6% AU$ 51 Value of obesity risk reduction 26% 22% AU$ 53 30 AU$ 57 Value of SIDS risk reduction 40% 18% AU$ 40 56% AU$ 67 Value of breast cancer risk reduction 4.3% 2.9% AU$ 54 5.8% AU$ 57 Total value of outcome On average AU$ 99,867 Value divided by 2 AU$ 27 Value multiplied by 2 AU$ 112 Birth type Single birth (N=1000) Twins and triplet (N=700) AU$ 52 All scenarios tested demonstrated the SROI ratio in favor of the BHFI was >1, indicating that social value of the BHFI is likely to be greater than the investment made in the program. Discussion Our results demonstrate that every investment of AU$1 drives a social return of AU$55. This evaluation also demonstrated the impact of the BHFI whose principal goals are to ensuring maternity service quality is equitable for every mother and family. Other studies have also found a positive social return for breastfeeding support programs; for example, a nutritional counselling and breastfeeding support program in Nairobi brought US$71 for every US$1 invested (57). A breastfeeding group facilitated by Public Health Nurse in Ireland brought €15.85 for every €1 invested (50). To the best of our knowledge, there are few studies using SROI to examine programs related to breastfeeding. One strength of the SROI methodology includes deep engagement with stakeholders, enabling practice-based identification of outcomes and values. Difficulties can be encountered in valuing outcomes and what might have happened anyway. This type of research is most commonly conducted by consultants, which can be costly (58). There are few peer-reviewed reports of SROI in the public domain, limiting our capacity to compare our findings with those from previous studies (58). Modelling conducted for the Lancet Breastfeeding Series estimates that global economic losses related to lower cognition from not breastfeeding reached a staggering US$302 billion in 2012, equivalent to 0.49% of world gross national income. In high-income countries alone these losses amounted to US$231.4 billion, equivalent to 0.53% of gross national income (7). The annual cost of not breastfeeding according to WHO recommendations (six months of exclusive breastfeeding and continued breastfeeding until two years old or beyond) globally was approximately US$1.1 billion annually from preventable maternal and infant morbidity and mortality (59). In the Australian Capital Territory alone, the cost of treating five common but preventable diseases by breastfeeding (gastrointestinal illness, respiratory illness, otitis media, eczema and necrotizing enterocolitis) was estimated at AU$1-2 million annually in 2001 (60). An American study of suboptimal breastfeeding cost of necrotizing enterocolitis morbidity and mortality in extremely low birth weight newborn calculated US$27.1 million in direct medical costs, US$563,655 in indirect nonmedical costs and US$1.5 billion in cost attributable to premature death (61). The promotion of breastfeeding is protective of both the health and wealth of society. As part of our SROI analysis, stakeholder engagement did not provide all the inputs to the SROI model resulting in some of the outcome values being taken from the literature. Compared to the conventional Return on Investment analysis, SROI not only calculates benefits against capital invested, but also takes into account externalities (spillover effects from the intervention) (62). In fact, in the real world there are no activities entirely limited to its direct impacts, as there are consequences which also affect broader social, economic and environmental dimensions (62). Breast feeding can play an important role in narrowing health inequalities. Low breastfeeding rates are related to several factors, and exacerbated by disparities including access to services and socioeconomic and educational background of the mother (63, 64). Pregnancy presents a unique opportunity for a universal population health intervention to reduce social inequalities. As shown by this research embedding breastfeeding support programs, such as the BFHI, into routine care benefits society and contributes significantly to reducing infant and mother health disparities. In a publicly funded health system, like Australia’s, it provides an opportunity to intervene before systemic barriers that create differential experiences for mothers occur (65). There is overwhelming evidence that the benefits of breastfeeding in both the short and long term enable infants to have the best possible health regardless of family’s social and economic background. Empowering mothers and families with information that breastfeeding to provides the ideal nutrition for children could also meet other policy aims of government. A key aim of the Australian government’s closing the gap policy is targeted at improving Aboriginal and Torres Strait Islander health and to halve the gap in child (ages 0–4) mortality rates. Within the indigenous community infant and child mortality is twice as likely before the age of 5, than their non-indigenous counterparts (66). Research has shown that Indigenous women are less likely to breastfeed their babies (67). One of the reasons attributed to this decrease is lack of professional support services (68) such as those offered by the BFHI Ten Steps criteria for quality maternal and newborn care. The perceived lack of policy commitment might be due to low valuation of breastfeeding as a result of the invisibility of breastfeeding and breast milk’s contribution from an economic perspective (64). Breastfeeding and breast milk are perceived as free products, even though it is not free when it costs mother’s time and effort. One Australian study measured the value of human milk in economic production statistic (e.g. gross domestic product/GDP) and showed that human milk production levels exceed $3 billion annually (64). Supporting mothers in the early days after birth in hospital through the BFHI is essential for health equity, as exclusive breastfeeding in hospital is associated with longer duration of breastfeeding (18, 19, 21, 69), particularly in mothers from lower socioeconomic backgrounds (70). The BHFI represents an initiative that is available for all, regardless of their socioeconomic status, and it address inequalities throughout the lifetime. Implication The results of our study align with previous research regarding the SROI of breastfeeding programs. Investment in breastfeeding support programs, including the BFHI, benefits the community. As the social benefits are greater than the investment and it provides the best start for every infant, the BFHI needs to be prioritized by the government. In principal, the Australian government supports and promotes breastfeeding, and specifically the BFHI, at the national (68, 71, 72) and state and territory levels (73-75); however there is lack of follow-up action. The Best Start report recommended the BFHI to be integrated with national accreditation standards since 2007 (68) and the National Breastfeeding Strategy, which includes the BFHI integration into the national standards, however neither recommendation has been actioned (76). Breastfeeding and breast milk are perceived as free products, even though it is not free when it costs mother’s time and effort. Limitations This study measured the benefits compared to the cost invested by the hospital. Nevertheless, our study did not include cost savings for healthcare providers, which were not taken into account due to large gaps in the literature relevant to the Australian health system. There is also no literature on the benefits to healthcare professionals in implementing the BFHI. Moreover, mothers’ time and effort to breastfeed were not included in the calculation, with only limited data on this important investment available in the current literature (77-79). The impact of breastfeeding support programs on mothers is well documented (80-82); however, elucidation of the SROI from mothers’ perspectives would be of great value in further clarifying the social impact of implementing the BFHI. Our examination of the SROI of implementation of the BFHI in one public hospital in Canberra, Australia provides the foundation for future research in other hospitals and community settings. Conclusion The results of our study indicate that implementation of the Ten Steps and the BFHI is worth the investment; the social return received was far greater than the investment. BFHI accreditation is a way to ensure equitable quality maternity care. This study was the first that measured social return of BFHI accreditation and provides strong evidence to prioritize the BFHI at a national level. Declarations Ethics approval and consent to participate The ethics for this study was approved by The Australian National University Human Research Ethics Committees (Protocol 2019/227) and the Calvary Hospital Ethics Committee. Written informed consents were obtained from the Director of Midwifery, the Clinical Midwife Consultant, and the Clinical Midwifery Educator. Consent for publication The ethical approval provides the consent for publication. Availability of supporting data The data that support the findings of this study are available from the corresponding author upon reasonable request. Competing interest The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article. Funding This study is funded by Indonesian Endowment Fund for Education (LPDP) and Department of Health Services Research and Policy, Research School of Population Health, Australian National University. Authors information Affiliations Department of Health Services Research and Policy, Research School of Population Health, College of Health and Medicine, Australian National University, 63 Eggleston Road, Acton 0200, Canberra, Australian Capital Territory, Australia. Andini Pramono, Julie Smith, Jane Desborough and Siobhan Bourke Authors’ contributions AP, JD and SB collected data; AP and SB conducted SROI analysis; AP, SB, JS and JD drafted and revised the paper. All authors read and approved the final manuscript. Acknowledgement We would like to acknowledge the Director of Midwifery, the Clinical Midwife Consultant, and the Clinical Midwifery Educator of Calvary Public Hospital Canberra, Australia. References Amir LH, Donath SM. Socioeconomic status and rates of breastfeeding in Australia: evidence from three recent national health surveys. Med J Aust. 2008;189(5):254-6. Grummer-Strawn LM, Rollins N. Summarising the health effects of breastfeeding. Acta Paediatrica. 2015;104(S467):1-2. Victora CG, Bahl R, Barros AJD, França GVA, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet. 2016;387(10017):475-90. Al Mamun A, O'Callaghan MJ, Williams GM, Najman JM, Callaway L, McIntyre HD. Breastfeeding is protective to diabetes risk in young adults: a longitudinal study. Acta Diabetol. 2015;52(5):837-44. World Health Organization. Exclusive breastfeeding for six months best for babies everywhere 2011 [Available from: https://www.who.int/mediacentre/news/statements/2011/breastfeeding_20110115/en/ . World Health Organization, UNICEF. Tracking Progress for Breastfeeding Policies and Programmes. 2017. Victora C, Rollins N. Failing to breastfeed costs the global economy around US$302 billion every year: The Lancet; 2016 [Available from: https://www.unicef.org.uk/babyfriendly/lancet-increasing-breastfeeding-worldwide-prevent-800000-child-deaths-every-year/ . Heck KE, Braveman P, Cubbin C, Chávez GF, Kiely JL. Socioeconomic Status and Breastfeeding Initiation among California Mothers. Public Health Reports. 2006;121(1):51-9. Chang P-C, Li S-F, Yang H-Y, Wang L-C, Weng C-Y, Chen K-F, et al. Factors associated with cessation of exclusive breastfeeding at 1 and 2 months postpartum in Taiwan. International Breastfeeding Journal. 2019;14(1):18. Kohlhuber M, Rebhan B, Schwegler U, Koletzko B, Fromme H. Breastfeeding rates and duration in Germany: a Bavarian cohort study. British Journal of Nutrition. 2008;99(5):1127-32. de Almeida JM, de Araújo Barros Luz S, da Veiga Ued F. Support of breastfeeding by health professionals: integrative review of the literature. Revista Paulista de Pediatria (English Edition). 2015;33(3):355-62. Merz C, Shield A, McClatchey A. Breastfeeding education provided to university health students: is it enough to support breastfeeding women? Research in Social and Administrative Pharmacy. 2019;15(5):e25. World Health Organization, Unicef. Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-Friendly Hospital Initiative 2018 2018 [Available from: http://www.who.int/nutrition/publications/infantfeeding/bfhi-implementation/en/ . Pramono A, Desborough J, Smith J. The Ten Steps to Successful Breastfeeding Policy Review. Breastfeeding Review. 2019;27(3):14. World Health Organization. Baby Friendly Hospital Initiative 2018 [Available from: http://www.who.int/nutrition/topics/bfhi/en/ . Australian College of Midwives. Baby Friendly Health Initiative (BFHI) Accreditation 2018 [Available from: https://www.midwives.org.au/baby-friendly-health-initiative-bfhi-accreditation . Perez-Escamilla R, Martinez J, Segura-Perez S. Impact of the Baby-Friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review. Maternal and Child Nutrition. 2016;12:13. Fallon A, Crepinsek M, Hegney D, O'Brien M. The Baby-Friendly Hospital Initiative and Breastfeeding Duration: Relating the Evidence to the Australian Context2005. Broadfoot M, Britten J, Tappin DM, MacKenzie JM. The Baby Friendly Hospital Initiative and breast feeding rates in Scotland. Arch Dis Child Fetal Neonatal Ed. 2005;90(2):F114-6. Munn AC, Newman SD, Mueller M, Phillips SM, Taylor SN. The Impact in the United States of the Baby-Friendly Hospital Initiative on Early Infant Health and Breastfeeding Outcomes. Breastfeed Med. 2016;11:222-30. Spaeth A, Zemp E, Merten S, Dratva J. Baby-Friendly Hospital designation has a sustained impact on continued breastfeeding. Maternal & Child Nutrition. 2018;14(1):e12497. Silva OLdO, Rea MF, Sarti FM, Buccini G. Cost-effectiveness analysis of Baby-Friendly Hospital Initiative in promotion of breast-feeding and reduction of late neonatal infant mortality in Brazil. Public Health Nutrition. 2020:1-11. World Health Organization. National Implementation of the Baby-Friendly Hospital Initiative 2017. 2017. BFHI Australia. About BFHI 2020 [Available from: https://bfhi.org.au/about/ . World Health Organization, United Nations Children's Fund (UNICEF). Compendium of Case Studies of the Baby Friendly Hospital Initiative. 2017. Atchan M, Davis D, Foureur M. The impact of the Baby Friendly Health Initiative in the Australian health care system: a critical narrative review of the evidence. Breastfeed Rev. 2013;21(2):15-22. Atchan M, Davis D, Foureur M. An instrumental case study examining the introduction and dissemination of the Baby Friendly Health Initiative in Australia: Participants’ perspectives. Women and Birth. 2018;31(3):210-9. Atchan M, Davis D, Foureur M. Applying a knowledge translation model to the uptake of the Baby Friendly Health Initiative in the Australian health care system. Women and Birth. 2014;27(2):79-85. Australian Institute of Health and Welfare. Australia's mothe and babies 2018: in brief. Canberra; 2020. The SROI Network. A Guide to Social Return on Investment. 2015. Chowdhury R, Sinha B, Sankar MJ, Taneja S, Bhandari N, Rollins N, et al. Breastfeeding and maternal health outcomes: a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):96-113. Carter CM. Breastfeeding at work benefits mom, baby and the employer 2019 [Available from: https://www.forbes.com/sites/christinecarter/2019/07/31/breastfeeding-at-work-benefits-mom-baby-and-the-employer/#29163126675f . Babic A, Sasamoto N, Rosner BA, Tworoger SS, Jordan SJ, Risch HA, et al. Association Between Breastfeeding and Ovarian Cancer Risk. JAMA Oncology. 2020;6(6):e200421-e. Ranadip C, Bireshwar S, Jeeva SM, Sunita T, Nita B, Nigel R, et al. Breastfeeding and maternal health outcomes: a systematic review and meta-analysis. Acta Paediatrica. 2015;104(S467):96-113. Unar-Munguía M, Torres-Mejía G, Colchero MA, González de Cosío T. Breastfeeding Mode and Risk of Breast Cancer: A Dose–Response Meta-Analysis. Journal of Human Lactation. 2017;33(2):422-34. Binns C, Lee M, Low WY. The Long-Term Public Health Benefits of Breastfeeding. Asia Pacific Journal of Public Health. 2016;28(1):7-14. Anderson JW, Johnstone BM, Remley DT. Breast-feeding and cognitive development: a meta-analysis. Am J Clin Nutr. 1999;70(4):525-35. Frank NM, Lynch KF, Uusitalo U, Yang J, Lönnrot M, Virtanen SM, et al. The relationship between breastfeeding and reported respiratory and gastrointestinal infection rates in young children. BMC Pediatrics. 2019;19(1):339. Thompson JMD, Tanabe K, Moon RY, Mitchell EA, McGarvey C, Tappin D, et al. Duration of Breastfeeding and Risk of SIDS: An Individual Participant Data Meta-analysis. Pediatrics. 2017;140(5):e20171324. Lamberti LM, Fischer Walker CL, Noiman A, Victora C, Black RE. Breastfeeding and the risk for diarrhea morbidity and mortality. BMC Public Health. 2011;11(3):S15. Victora CG, Horta BL, de Mola CL, Quevedo L, Pinheiro RT, Gigante DP, et al. Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil. The Lancet Global Health. 2015;3(4):e199-e205. Krol KM, Grossmann T. Psychological effects of breastfeeding on children and mothers. Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz. 2018;61(8):977-85. Herrmann K, Carroll K. An exclusively human milk diet reduces necrotizing enterocolitis. Breastfeed Med. 2014;9(4):184-90. Horta BL, Loret de Mola C, Victora CG. Breastfeeding and intelligence: a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):14-9. Woo JG, Martin LJ. Does Breastfeeding Protect Against Childhood Obesity? Moving Beyond Observational Evidence. Curr Obes Rep. 2015;4(2):207-16. Barker SF, Zomer E, O'Toole J, Sinclair M, Gibney K, Liew D, et al. Cost of gastroenteritis in Australia: A healthcare perspective. PLoS One. 2018;13(4):e0195759. Newall AT, Scuffham PA. Influenza-related disease: the cost to the Australian healthcare system. Vaccine. 2008;26(52):6818-23. Taylor PS, Faeth I, Marks MK, Del Mar CB, Skull SA, Pezzullo ML, et al. Cost of treating otitis media in Australia. Expert Review of Pharmacoeconomics & Outcomes Research. 2009;9(2):133-41. Drane D. Breastfeeding and formula feeding: a preliminary economic analysis. Breastfeeding Review. 1997;5(1). Hanafin S, O’Dwyer K, Creedon M, Clune Mulvaney C. Social Return on Investment: PHN-facilitated breastfeeding groups in Ireland. Research Matters Ltd; 2018. Colagiuri S, Lee CM, Colagiuri R, Magliano D, Shaw JE, Zimmet PZ, et al. The cost of overweight and obesity in Australia. Med J Aust. 2010;192(5):260-4. Lee CMY, Goode B, Nørtoft E, Shaw JE, Magliano DJ, Colagiuri S. The cost of diabetes and obesity in Australia. J Med Econ. 2018;21(10):1001-5. Goldsbury DE, Yap S, Weber MF, Veerman L, Rankin N, Banks E, et al. Health services costs for cancer care in Australia: Estimates from the 45 and Up Study. PLoS One. 2018;13(7):e0201552. Mathers C, Penm R. Health system costs of cardiovascular diseases and diabetes in Australia 1993-94. Australian Institute of Health and Welfare; 1997. World Health Organization. Costs and savings. 2009. In: Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care [Internet]. Geneva: World Health Organization. Available from: https://www.ncbi.nlm.nih.gov/books/NBK153460/ . Deans J. Discount rates for Commonwealth infrastructure projects 2018 [Available from: https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/FlagPost/2018/October/Discount-rates . Goudet S, Griffiths PL, Wainaina CW, Macharia TN, Wekesah FM, Wanjohi M, et al. Social value of a nutritional counselling and support program for breastfeeding in urban poor settings, Nairobi. BMC Public Health. 2018;18(1):424. Hutchinson CL, Berndt A, Forsythe D, Gilbert-Hunt S, George S, Ratcliffe J. Valuing the impact of health and social care programs using social return on investment analysis: how have academics advanced the methodology? A systematic review. BMJ Open. 2019;9(8):e029789. Walters DD, Phan LTH, Mathisen R. The cost of not breastfeeding: global results from a new tool. Health Policy and Planning. 2019. Smith JP, Thompson JF, Ellwood DA. Hospital system costs of artificial infant feeding: estimates for the Australian Capital Territory. Aust N Z J Public Health. 2002;26(6):543-51. Colaizy T, Bartick M, Jegier B, Brittany, Green D, Reinhold AG, et al., editors. Impact of suboptimal breastfeeding on the healthcare and mortality costs of necrotizing enterocolitis in extremely low birthweight infants2017. Hamelmann C, Turatto F, Then V, Dyakova M. Social return on investment: accounting for value in the context of implementing Health 2020 and the 2030 Agenda for Sustainable Development. In: Europe WHOROf, editor. Investment for health and development discussion paper. Copenhagen2017. Lutter CK, Chaparro CM, Grummer-Strawn LM. Increases in breastfeeding in Latin America and the Caribbean: an analysis of equity. Health Policy and Planning. 2010;26(3):257-65. Smith JP. “Lost Milk?”:Counting the Economic Value of Breast Milk in Gross Domestic Product. Journal of Human Lactation. 2013;29(4):537-46. Robertson A. Breastfeeding initiation at birth can help reduce health inequalities. In: WHO Collaborating Centre in Global Nutrition and Health, editor. Denmark2015. Australian Institute of Health and Welfare. Australia's Health 2018. 2018. McLachlan HL, Shafiei T, Forster DA. Breastfeeding initiation for Aboriginal and Torres Strait Islander women in Victoria: analysis of routinely collected population-based data. Women and Birth. 2017;30(5):361-6. Standing Committee on Health and Ageing. The Best Start: Report on the inquiry into the health benefits of breastfeeding. Canberra, Australia: Commonwealth of Australia; 2007. Merten S, Dratva J, Ackermann-Liebrich U. Do baby-friendly hospitals influence breastfeeding duration on a national level? Pediatrics. 2005;116(5):e702-8. Vehling L, Chan D, McGavock J, Becker AB, Subbarao P, Moraes TJ, et al. Exclusive breastfeeding in hospital predicts longer breastfeeding duration in Canada: Implications for health equity. Birth. 2018;45(4):440-9. Commonwealth Department of Health and Aged Care. National Breastfeeding Strategy summary report. In: Care DoHaA, editor. Canberra, ACT.: Commonwealth of Australia; 2001. Australian Health Ministers' Conference. 2010 Implementation Plan for the Australian National Breastfeeding Strategy 2010-2015. In: Health Do, editor. Canberra, Australia: Australian Government Department of Health; 2010. State of Victoria Department of Health and Human Services. Maternal and Child Health Services guidelines. In: Department of Health and Human Services, editor. 2019. Western Australia Country Health Service. WA Country Health Service Maternal and Newborn Care Strategy 2019-2024. Western Australia2018. NSW Government. Breastfeeding in NSW - Promotion, Protection and Support. In: Ageing DoHa, editor. New South Wales2018. COAG Health Council. Australian National Breastfeeding Strategy 2019 and beyond. 2019. Smith JP, Forrester R. Who pays for the health benefits of exclusive breastfeeding? An analysis of maternal time costs. J Hum Lact. 2013;29(4):547-55. Smith JP, Forrester R. Maternal Time Use and Nurturing: Analysis of the Association Between Breastfeeding Practice and Time Spent Interacting with Baby. Breastfeeding Medicine. 2017. Jegier BJ, Meier P, Engstrom JL, McBride T. The initial maternal cost of providing 100 mL of human milk for very low birth weight infants in the neonatal intensive care unit. Breastfeeding Medicine. 2010;5(2):71-7. Trickey H, Thomson G, Grant A, Sanders J, Mann M, Murphy S, et al. A realist review of one‐to‐one breastfeeding peer support experiments conducted in developed country settings. Maternal & Child Nutrition. 2018;14(1). Forster DA, McLardie-Hore FE, McLachlan HL, Davey M-A, Grimes HA, Dennis C-L, et al. Proactive Peer (Mother-to-Mother) Breastfeeding Support by Telephone (Ringing up About Breastfeeding Early [RUBY]): A Multicentre, Unblinded, Randomised Controlled Trial. EClinicalMedicine. 2019;8:20-8. Schmied V, Burns E, Sheehan A. Place of sanctuary: an appreciative inquiry approach to discovering how communities support breastfeeding and parenting. International Breastfeeding Journal. 2019;14(1):25. Australian Government Fair Work Ombudsman. Pay Guide - Nurses Award. 2020. Supplementary Files Appendix1.docx Cite Share Download PDF Status: Published Journal Publication published 07 Jan, 2021 Read the published version in International Journal for Equity in Health → Version 1 posted Review # 2 received at journal 12 Nov, 2020 Editorial decision: Major Revision 12 Nov, 2020 Review # 1 received at journal 02 Nov, 2020 Reviewer # 2 agreed at journal 24 Oct, 2020 Reviewer # 1 agreed at journal 21 Oct, 2020 Editor assigned by journal 20 Oct, 2020 Reviewers invited by journal 20 Oct, 2020 Submission checks completed at journal 19 Oct, 2020 Editor invited by journal 19 Oct, 2020 First submitted to journal 18 Oct, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-97226","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research","associatedPublications":[],"authors":[{"id":3882988,"identity":"c6c7469a-7072-4b00-939a-77c82d484c01","order_by":0,"name":"Andini Pramono","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYHACgwMMBnCODYTiIUFLGnFakDmHCWvhn9288XBBAUOeefvpxMcFFeflzSUSGB+8bWOQB9qOFUjcOVZweIYBQ7HMmdzNxjPO3DbcOSOB2XBuG4PhBhxaGG7kGBzmMWBInMGQu02at+0244YbCWxABgMjLi3ycC38b0FaztkDtbD/Bmqxx6XFAK5FAmzLgUSQLcxALYm4tBjeSCsAapEolpB4u9mY50xy8oYzD5sl55yTSJ6JQ4vcjeTNn3n+2ORJ8OdufMxTYWe74XjywQ9vymxs+3B5HwIkEpA4jA0gEbzqQSCBoIpRMApGwSgYuQAA5Otcnc3+tvMAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-5361-8715","institution":"Australian National University Research School of Population Health","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Andini","middleName":"","lastName":"Pramono","suffix":""},{"id":3882989,"identity":"14b50fdc-02af-4e48-a969-214e63ac5185","order_by":1,"name":"Julie Smith","email":"","orcid":"","institution":"Australian National University Research School of Population Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Julie","middleName":"","lastName":"Smith","suffix":""},{"id":3882990,"identity":"c8a6a6dd-0de5-4118-ba64-c41654112f35","order_by":2,"name":"Jane Desborough","email":"","orcid":"","institution":"Australian National University Research School of Population Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jane","middleName":"","lastName":"Desborough","suffix":""},{"id":3882991,"identity":"fd43e53f-4533-4ed9-be86-7fde8981f97d","order_by":3,"name":"Siobhan Bourke","email":"","orcid":"","institution":"Australian National University Research School of Population Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Siobhan","middleName":"","lastName":"Bourke","suffix":""}],"badges":[],"createdAt":"2020-10-23 13:58:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-97226/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-97226/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12939-020-01365-3","type":"published","date":"2021-01-07T15:03:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":13608481,"identity":"2c18839a-f1e8-459a-8af0-7909ae8faa25","added_by":"auto","created_at":"2021-09-17 06:16:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":465737,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-97226/v1/be2f8100-d843-43c4-b5fb-662cba1ee2be.pdf"},{"id":3253874,"identity":"a109a00d-3abb-43ba-b085-146d662deead","added_by":"auto","created_at":"2020-10-28 21:57:15","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15502,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-97226/v1/b69d0119b8ef87235cfae115.docx"}],"financialInterests":"","formattedTitle":"\u003cp\u003eSocial Value of Baby-Friendly Hospital Initiative Implementation in Australia: Case Study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eBreastfeeding is the normal biological standard of infant feeding. It has benefits to infant and maternal health, and reduces health inequality, as well as reducing harmful impacts to the environment and decreasing health expenditure attributed to preventable illness. Socioeconomic groups with lower education and income levels are less likely to breastfeed when compared to their higher education and income group peers (1). Children who are not breastfed have, inter alia, higher rates of obesity, malocclusion and asthma, and lower intelligence quotients (2), while a lack of breastfeeding increases maternal risk of ovarian cancer, breast cancer, type 2 diabetes and osteoporosis (3, 4). The World Health Organization (WHO) recommends breastfeeding exclusively for the first six months of infants\u0026rsquo; life (5). Despite the benefits, the exclusive breastfeeding rate globally is only 41% (6). High-income countries such as Australia have shorter breastfeeding duration than low- and middle-income countries, even though breastfeeding has been proven to reduce the risk of sudden infant deaths by more than one third in high-income countries and half of all diarrhea episodes and a third of respiratory infections in low and middle-income countries (7).\u003c/p\u003e\n\u003cp\u003eFactors associated to low breastfeeding initiation and/or duration include maternal and paternal lower education (8, 9), partners\u0026rsquo; negative attitudes towards breastfeeding (10), mother/baby separation after birth (9) and lack of health professionals\u0026rsquo; knowledge of breastfeeding (11, 12). The first few hours and days of an infant\u0026rsquo;s life are critical to establish breastfeeding. Therefore, WHO launched Ten Steps to Successful Breastfeeding in 1989 and Baby Friendly Hospital Initiative (BFHI) in 1991 to focus on providing a high standard of maternity services to enable every infant to attain the best nutrition standards available. In 2018, WHO revised the Ten Steps (13). The revisions are subtle, but meaningful for implementation, with the focus shifted from healthcare staff to parents and families, empowering and enabling women and families to make choices regarding infant feeding method based on information free from conflict of interest (14). BFHI status is awarded to hospitals that implement high quality maternity care through the Ten Steps to Successful Breastfeeding policy; while remaining independent from formula companies and their affiliates (15), and re-assessed every three years (16). UNICEF Australia passed governance of BFHI within Australia to Australian College of Midwives (16). In 2006, the Australian Baby Friendly Hospital Initiative became the Baby Friendly \u003cem\u003eHealth \u003c/em\u003eInitiative in order to more accurately reflect the expansion of the initiative into community health facilities (16).\u003c/p\u003e\n\u003cp\u003eImplementing the Ten Steps and achieving BFHI accreditation is essential to ensure quality of maternity care received by mothers and families, regardless of their social, economic, race and religious background. The benefits of implementing Ten Steps and achieving BFHI accreditation and its impact on breastfeeding has been demonstrated in research internationally (17-21), and the cost-effectiveness of BFHI in reducing late neonatal infant mortality rate has been established (22). Despite evidence that the BFHI improves the wellbeing of mothers and significantly increases the duration of breastfeeding (17), only 10% of births occur in maternity services that are designated as baby-friendly internationally (23), and only 77 out of 266 maternity services (26%) in Australia are baby-friendly accredited as of 2020 (24). Several Australian studies showed barriers to BFHI implementation that are similar to those described internationally (25), such as lack of policy support and funding due to the low priority and value of breastfeeding (26, 27).\u003c/p\u003e\n\u003cp\u003eOne Australian study showed that perception that the cost of BFHI accreditation may outweigh the benefit which could hinder the scale up of the BFHI program in Australia (28). No studies have explored the social return on investment of the BFHI in the Australian context.\u003c/p\u003e\n\u003ch2\u003eResearch aim/question\u003c/h2\u003e\n\u003cp\u003eThis study aimed to examine the social return on investment (SROI) of implementing the BFHI in one public maternity unit in Australia.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eSample and location\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in an Australian BFHI-accredited public hospital in August 2019. We selected this hospital because three in four Australian mothers give birth in public hospital (29) and this particular hospital has been BFHI-friendly accredited for 15 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterviews aimed to elucidate the costs of implementing the BFHI. Underpinned by the principles of the Social Return on Investment (SROI) framework, and in collaboration with the Director of Midwifery, the Clinical Midwife Consultant, and the Clinical Midwifery Educator, we developed a structured questionnaire based on the 2018 Ten Steps to Successful Breastfeeding (Ten Steps) which was used for the interview. The interview was conducted on 21\u003csup\u003est\u003c/sup\u003e August 2019 and took one and a half hours.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData storage\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe interview was audio-recorded and then transcribed verbatim. Data was stored on password protected computer at the university and only accessible to the primary researcher.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData was analyzed in excel using the SROI framework, which uses monetary values to measure social, environmental and economic outcomes of change. The SROI is a framework for measuring and accounting for the much broader concept of value; it seeks to reduce inequality and environmental degradation, and improve wellbeing by incorporating social, environmental and economic costs and benefits (30). The benefits of breastfeeding are associated with a wide range of outcomes including health and social benefits. Therefore, the SROI methodology was relevant to help understand the value created by these programs to inform policy making. The information obtained in the interviews was supplemented with evidence-based estimations from the literature that measured the benefits of the BFHI. SROI analysis involves a 5-step process: establishing scope and involving stakeholders, mapping outcomes, evidencing and valuing outcomes, establishing impact, and calculating the SROI ratio. Each step is explained in detail below.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEstablishing scope and involving stakeholders\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst, we identified the stakeholders for SROI analysis. For our analysis, implementation of the Ten Steps as a framework for the BFHI involved two main stakeholders: the mother and baby dyad, and the maternity facility. These two main stakeholders were included as they were identified to derive the greatest benefits from Ten Steps implementation and sufficient evidence was available, and it was feasible to measure and include.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMapping outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSecond, we mapped the outcomes for each stakeholder. A theory of change was developed from the literature, representing how the BHFI were expected to bring about change. For mothers, the benefits included risk reduction of breast cancer, cardiovascular disease, ovarian cancer, hypertension, and for no cost related to buying formula (3, 31-35). For babies, the benefits include reduced risk of diarrhea, respiratory infection, acute otitis media, necrotizing enterocolitis, obesity, Sudden Infant Death Syndrome (SIDS) diabetes, and higher IQ (2, 36-45).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvidencing and valuing outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThird, we searched the literature to evidence outcomes (Table 1). The cost in achieving BFHI accreditation based on interview findings (see Appendix 1). From the interview, costs relating to the BFHI application fee, lunch cost for the assessors, human resource relating to the cost of policy revision, BFHI system monitoring and compliance, breastfeeding counseling, staff training, as well as printing and laminating cost, provision of breastfeeding tools (e.g. nipple shield, pill-cups for cup feeding, hospital-grade breast-pump) and formula purchase for special-needs, preterm and low birth weight babies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Financial proxy used to allocate a market price\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003e\u003cstrong\u003eBabies\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"270\"\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial proxy\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eCost\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003eReduce risk of diarrhea\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"270\"\u003e\n\u003cp\u003eCost of gastrointestinal (46)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eAUD 20.27\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003eReduce risk of respiratory infection\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"270\"\u003e\n\u003cp\u003eCost of influenza-related disease (47)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eAUD 2,864\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003eReduce risk of acute otitis media\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"270\"\u003e\n\u003cp\u003eCost of treating otitis media in Australia (48)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eAUD 594\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003eReduce risk of necrotizing enterocolitis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"270\"\u003e\n\u003cp\u003eCost of NEC treatment (49)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eAUD 13,863\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003eHigher IQ\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"270\"\u003e\n\u003cp\u003eAnnual earnings (average weekly income in Australia (50) x 52 weeks)*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eAUD 89,487\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003eReduce risk of obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"270\"\u003e\n\u003cp\u003eCost of obesity in Australia (51)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eAUD 2,500\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003eReduce risk of type 1 diabetes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"270\"\u003e\n\u003cp\u003eCost of diabetes in Australia (52)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"138\"\u003e\n\u003cp\u003eAUD 3,131\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003eReduce risk of type 2 diabetes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003eReduce risk of Sudden Infant Death Syndrome (SIDS)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"270\"\u003e\n\u003cp\u003eAnnual earnings (average weekly income in Australia (50) x 52 weeks)*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eAUD 89,487\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003e\u003cstrong\u003eMothers \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"270\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003eReduce risk of breast cancer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"270\"\u003e\n\u003cp\u003eCost of breast cancer treatment per case in Australia (53)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eAUD 36,448\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003eReduce risk of cardiovascular disease\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"270\"\u003e\n\u003cp\u003eCost of cardiovascular disease treatment in hospital in Australia (54)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eAUD 1,700\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003eNot buying formula\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"270\"\u003e\n\u003cp\u003eFormula supply for one year for full formula-fed baby (1.5 tins for a week for the first 6 months and 0.6 tin for a week for the next 6 months) *\u003c/p\u003e\n\u003cp\u003eWe followed WHO guidance (55) and adapt it to Australian settings\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eAUD 1,160\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003eReduce risk of ovarian cancer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"270\"\u003e\n\u003cp\u003eCost of ovarian cancer treatment per person in Australia (53)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eAUD 31,958\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"216\"\u003e\n\u003cp\u003eReduce risk of hypertension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"270\"\u003e\n\u003cp\u003eCost of hypertension treatment per diagnosed case (54)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eAUD 570\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"623\"\u003e\n\u003cp\u003e*assumption\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eEstablishing Impact\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDeadweight, attribution, and displacement were subtracted from the outcome to reduce the risk of over-claiming benefits. To determine the specific value, we reviewed the literature on breastfeeding. Deadweight relates to a change that would have happened anyway even if BFHI was not implemented; we assumed that 5% of benefits would have happened without the BFHI. Displacement is an assessment of how much of the outcome\u0026nbsp;displaced\u0026nbsp;other outcomes; we assumed the BFHI would displace 20% of other activity. Attribution is the term used for change that occurred caused by other intervention; we assumed 25% of benefits were attributed to other activities. We also assumed that 20% of the benefits would decline (drop off) over time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCalculating the SROI and sensitivity analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this step we estimated how long the outcomes will last and used them in the analysis. Here we knew the duration of the outcome due to earlier literature search and interviews. We assumed the benefit included the risk reduction of diarrhea, respiratory infection, acute otitis media and necrotizing enterocolitis lasted for three years; higher IQ, risk reduction of obesity, type 1 and type 2 diabetes and SIDS for 30 years; risk reduction of breast and ovarian cancer, hypertension and cardiovascular disease for 15 years; and formula supply for two years. The costs and benefits were discounted to calculate the net present value, to ensure that the costs and benefits in different time periods were comparable. The recommended rate of 4% (56) was used, recognizing the value of cash today is higher than value of cash in the future. This is the net present value (NPV). After the net present value was calculated, we subtracted the investment and then divided it by the total input, that being the total monetary investment in the BHFI.\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/58890_add8f4303ffe25fa/58890_custom_files/img1603883483.png\" alt=\"\" /\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a sensitivity analysis identifying the estimated with the greatest impact on the SROI ratio, to test how sensitive the ratio is to changes in these estimates including in the deadweight, displacement and attrition and specific estimates.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe average number of births in Calvary public hospital was 1000 annually, with exclusive breastfeeding rate on discharge of 97% in 2019. The value of benefits and costs is summarized in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Value of benefits and costs of BFHI accreditation at Calvary Public Hospital\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003e\u003cstrong\u003eBenefits\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e\u003cstrong\u003eAnnual amount in AUD\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003e\u003cstrong\u003eBabies\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003eReduce risk of diarrhea\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e3,004\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003eReduce risk of respiratory infection\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e41,138\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003eReduce risk of acute otitis media\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e36,397\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003eReduce risk of necrotizing enterocolitis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e100,591\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003eHigher IQ\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003eReduce risk of obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e276,832\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003eReduce risk of type 1 diabetes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e118\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003eReduce risk of type 2 diabetes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e33,106\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003eReduce risk of Sudden Infant Death Syndrome (SIDS)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e612,091\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003e\u003cstrong\u003eMothers \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003eReduce risk of breast cancer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e111,668\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003eReduce risk of cardiovascular disease\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e4,186\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003eNot buying formula\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e121,859\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003eReduce risk of ovarian cancer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e52,462\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003eReduce risk of hypertension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e4,679\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal value of benefits\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e\u003cstrong\u003e1,398,140\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003e\u003cstrong\u003eInvestments\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal value of investments\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e\u003cstrong\u003e24,433.80\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003e\u003cstrong\u003eNet Yield (benefits less investments)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e\u003cstrong\u003e1,373,705.73\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"378\"\u003e\n\u003cp\u003e\u003cstrong\u003eSocial Return on Investment (SROI)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"228\"\u003e\n\u003cp\u003e\u003cstrong\u003e55.38\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe social return (benefits) was calculated to be AU$ 1,398,140 and total investment required was AU$ 24,433 per year. Therefore, the SROI ratio was 55:1, which meant that every AU$ 1 invested in the BFHI generated approximately AU$55 of benefit to the Australian economy. The payback period was 0.63 month, which meant that all the investment would return in around 1 month.\u003c/p\u003e\n\u003cp\u003eFor our baseline estimation of the SROI we used conservative assumptions. We conducted sensitivity analysis by trying different assumptions (table 3). The SROI calculation was dominated by the high value of risk reduction in obesity and SIDS for babies as well as breast cancer risk reduction for mothers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Base and new case scenarios\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003e\u003cstrong\u003eSensitivity analysis\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e\u003cstrong\u003eBase case\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e\u003cstrong\u003eNew case\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e\u003cstrong\u003eNew ratio\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eAttribution\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e25%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e50%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eAU$ 37\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eDeadweight\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e50%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eAU$ 29\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eDisplacement\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e20%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eAU$ 69\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eDrop off\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e20%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e50%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eAU$ 16\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eDiscount rate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eAU$ 51\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"189\"\u003e\n\u003cp\u003eValue of obesity risk reduction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"156\"\u003e\n\u003cp\u003e26%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e22%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eAU$ 53\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eAU$ 57\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"189\"\u003e\n\u003cp\u003eValue of SIDS risk reduction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"156\"\u003e\n\u003cp\u003e40%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e18%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eAU$ 40\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e56%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eAU$ 67\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"189\"\u003e\n\u003cp\u003eValue of breast cancer risk reduction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"156\"\u003e\n\u003cp\u003e4.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e2.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eAU$ 54\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003e5.8%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eAU$ 57\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"189\"\u003e\n\u003cp\u003eTotal value of outcome\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"156\"\u003e\n\u003cp\u003eOn average AU$ 99,867\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003eValue divided by 2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eAU$ 27\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003eValue multiplied by 2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eAU$ 112\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"189\"\u003e\n\u003cp\u003eBirth type\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003eSingle birth (N=1000)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"156\"\u003e\n\u003cp\u003eTwins and triplet (N=700)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003eAU$ 52\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAll scenarios tested demonstrated the SROI ratio in favor of the BHFI was \u0026gt;1, indicating that social value of the BHFI is likely to be greater than the investment made in the program.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur results demonstrate that every investment of AU$1 drives a social return of AU$55. This evaluation also demonstrated the impact of the BHFI whose principal goals are to ensuring maternity service quality is equitable for every mother and family. Other studies have also found a positive social return for breastfeeding support programs; for example, a nutritional counselling and breastfeeding support program in Nairobi brought US$71 for every US$1 invested (57). A breastfeeding group facilitated by Public Health Nurse in Ireland brought \u0026euro;15.85 for every \u0026euro;1 invested (50).\u003c/p\u003e\n\u003cp\u003eTo the best of our knowledge, there are few studies using SROI to examine programs related to breastfeeding. One strength of the SROI methodology includes deep engagement with stakeholders, enabling practice-based identification of outcomes and values. Difficulties can be encountered in valuing outcomes and what might have happened anyway. This type of research is most commonly conducted by consultants, which can be costly (58). There are few peer-reviewed reports of SROI in the public domain, limiting our capacity to compare our findings with those from previous studies (58).\u003c/p\u003e\n\u003cp\u003eModelling conducted for the Lancet Breastfeeding Series estimates that global economic losses related to lower cognition from not breastfeeding reached a staggering US$302 billion in 2012, equivalent to 0.49% of world gross national income. In high-income countries alone these losses amounted to US$231.4 billion, equivalent to 0.53% of gross national income (7). The annual cost of not breastfeeding according to WHO recommendations (six months of exclusive breastfeeding and continued breastfeeding until two years old or beyond) globally was approximately US$1.1 billion annually from preventable maternal and infant morbidity and mortality (59). In the Australian Capital Territory alone, the cost of treating five common but preventable diseases by breastfeeding (gastrointestinal illness, respiratory illness, otitis media, eczema and necrotizing enterocolitis) was estimated at AU$1-2 million annually in 2001 (60). An American study of suboptimal breastfeeding cost of necrotizing enterocolitis morbidity and mortality in extremely low birth weight newborn calculated US$27.1 million in direct medical costs, US$563,655 in indirect nonmedical costs and US$1.5 billion in cost attributable to premature death (61). The promotion of breastfeeding is protective of both the health and wealth of society.\u003c/p\u003e\n\u003cp\u003eAs part of our SROI analysis, stakeholder engagement did not provide all the inputs to the SROI model resulting in some of the outcome values being taken from the literature. Compared to the conventional Return on Investment analysis, SROI not only calculates benefits against capital invested, but also takes into account externalities (spillover effects from the intervention) (62). In fact, in the real world there are no activities entirely limited to its direct impacts, as there are consequences which also affect broader social, economic and environmental dimensions (62).\u003c/p\u003e\n\u003cp\u003eBreast feeding can play an important role in narrowing health inequalities. Low breastfeeding rates are related to several factors, and exacerbated by disparities including access to services and socioeconomic and educational background of the mother (63, 64). Pregnancy presents a unique opportunity for a universal population health intervention to reduce social inequalities. As shown by this research embedding breastfeeding support programs, such as the BFHI, into routine care benefits society and contributes significantly to reducing infant and mother health disparities. In a publicly funded health system, like Australia\u0026rsquo;s, it provides an opportunity to intervene before systemic barriers that create differential experiences for mothers occur (65). There is overwhelming evidence that the benefits of breastfeeding in both the short and long term enable infants to have the best possible health regardless of family\u0026rsquo;s social and economic background. Empowering mothers and families with information that breastfeeding to provides the ideal nutrition for children could also meet other policy aims of government. A key aim of the Australian government\u0026rsquo;s closing the gap policy is targeted at improving Aboriginal and Torres Strait Islander health and to halve the\u0026nbsp;gap\u0026nbsp;in\u0026nbsp;child\u0026nbsp;(ages 0\u0026ndash;4)\u0026nbsp;mortality\u0026nbsp;rates. Within the indigenous community infant and child mortality is twice as likely before the age of 5, than their non-indigenous counterparts (66). Research has shown that Indigenous women are less likely to breastfeed their babies (67). One of the reasons attributed to this decrease is lack of professional support services (68) such as those offered by the BFHI Ten Steps criteria for quality maternal and newborn care.\u003c/p\u003e\n\u003cp\u003eThe perceived lack of policy commitment might be due to low valuation of breastfeeding as a result of the invisibility of breastfeeding and breast milk\u0026rsquo;s contribution from an economic perspective (64). Breastfeeding and breast milk are perceived as free products, even though it is not free when it costs mother\u0026rsquo;s time and effort. One Australian study measured the value of human milk in economic production statistic (e.g. gross domestic product/GDP) and showed that human milk production levels exceed $3 billion annually (64).\u003c/p\u003e\n\u003cp\u003eSupporting mothers in the early days after birth in hospital through the BFHI is essential for health equity, as exclusive breastfeeding in hospital is associated with longer duration of breastfeeding (18, 19, 21, 69), particularly in mothers from lower socioeconomic backgrounds (70). The BHFI represents an initiative that is available for all, regardless of their socioeconomic status, and it address inequalities throughout the lifetime.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplication \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results of our study align with previous research regarding the SROI of breastfeeding programs. Investment in breastfeeding support programs, including the BFHI, benefits the community. As the social benefits are greater than the investment and it provides the best start for every infant, the BFHI needs to be prioritized by the government. In principal, the Australian government supports and promotes breastfeeding, and specifically the BFHI, at the national (68, 71, 72) and state and territory levels (73-75); however there is lack of follow-up action. The Best Start report recommended the BFHI to be integrated with national accreditation standards since 2007 (68) and the National Breastfeeding Strategy, which includes the BFHI integration into the national standards, however neither recommendation has been actioned (76). Breastfeeding and breast milk are perceived as free products, even though it is not free when it costs mother\u0026rsquo;s time and effort.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study measured the benefits compared to the cost invested by the hospital. Nevertheless, our study did not include cost savings for healthcare providers, which were not taken into account due to large gaps in the literature relevant to the Australian health system. There is also no literature on the benefits to healthcare professionals in implementing the BFHI. Moreover, mothers\u0026rsquo; time and effort to breastfeed were not included in the calculation, with only limited data on this important investment available in the current literature (77-79). The impact of breastfeeding support programs on mothers is well documented (80-82); however, elucidation of the SROI from mothers\u0026rsquo; perspectives would be of great value in further clarifying the social impact of implementing the BFHI. Our examination of the SROI of implementation of the BFHI in one public hospital in Canberra, Australia provides the foundation for future research in other hospitals and community settings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results of our study indicate that implementation of the Ten Steps and the BFHI is worth the investment; the social return received was far greater than the investment. BFHI accreditation is a way to ensure equitable quality maternity care. This study was the first that measured social return of BFHI accreditation and provides strong evidence to prioritize the BFHI at a national level.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eThe ethics for this study was approved by The Australian National University Human Research Ethics Committees (Protocol 2019/227) and the Calvary Hospital Ethics Committee. Written informed consents were obtained from the Director of Midwifery, the Clinical Midwife Consultant, and the Clinical Midwifery Educator.\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eThe ethical approval provides the consent for publication.\u003c/p\u003e\n\u003ch3\u003eAvailability of supporting data\u003c/h3\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003ch3\u003eCompeting interest\u003c/h3\u003e\n\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eThis study is funded by Indonesian Endowment Fund for Education (LPDP) and Department of Health Services Research and Policy, Research School of Population Health, Australian National University.\u003c/p\u003e\n\u003ch2\u003eAuthors information\u003c/h2\u003e\n\u003ch3\u003eAffiliations\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eDepartment of Health Services Research and Policy, Research School of Population Health, College of Health and Medicine, Australian National University, 63 Eggleston Road, Acton 0200, Canberra, Australian Capital Territory, Australia.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAndini Pramono, Julie Smith, Jane Desborough and Siobhan Bourke\u003c/p\u003e\n\u003ch3\u003eAuthors\u0026rsquo; contributions\u003c/h3\u003e\n\u003cp\u003eAP, JD and SB collected data; AP and SB conducted SROI analysis; AP, SB, JS and JD drafted and revised the paper. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch3\u003eAcknowledgement\u003c/h3\u003e\n\u003cp\u003eWe would like to acknowledge the Director of Midwifery, the Clinical Midwife Consultant, and the Clinical Midwifery Educator of Calvary Public Hospital Canberra, Australia.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAmir LH, Donath SM. Socioeconomic status and rates of breastfeeding in Australia: evidence from three recent national health surveys. Med J Aust. 2008;189(5):254-6.\u003c/li\u003e\n\u003cli\u003eGrummer-Strawn LM, Rollins N. Summarising the health effects of breastfeeding. Acta Paediatrica. 2015;104(S467):1-2.\u003c/li\u003e\n\u003cli\u003eVictora CG, Bahl R, Barros AJD, Fran\u0026ccedil;a GVA, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet. 2016;387(10017):475-90.\u003c/li\u003e\n\u003cli\u003eAl Mamun A, O'Callaghan MJ, Williams GM, Najman JM, Callaway L, McIntyre HD. Breastfeeding is protective to diabetes risk in young adults: a longitudinal study. Acta Diabetol. 2015;52(5):837-44.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Exclusive breastfeeding for six months best for babies everywhere 2011 [Available from: \u003ca href=\"https://www.who.int/mediacentre/news/statements/2011/breastfeeding_20110115/en/\"\u003ehttps://www.who.int/mediacentre/news/statements/2011/breastfeeding_20110115/en/\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization, UNICEF. Tracking Progress for Breastfeeding Policies and Programmes. 2017.\u003c/li\u003e\n\u003cli\u003eVictora C, Rollins N. Failing to breastfeed costs the global economy around US$302 billion every year: The Lancet; 2016 [Available from: \u003ca href=\"https://www.unicef.org.uk/babyfriendly/lancet-increasing-breastfeeding-worldwide-prevent-800000-child-deaths-every-year/\"\u003ehttps://www.unicef.org.uk/babyfriendly/lancet-increasing-breastfeeding-worldwide-prevent-800000-child-deaths-every-year/\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003eHeck KE, Braveman P, Cubbin C, Ch\u0026aacute;vez GF, Kiely JL. Socioeconomic Status and Breastfeeding Initiation among California Mothers. Public Health Reports. 2006;121(1):51-9.\u003c/li\u003e\n\u003cli\u003eChang P-C, Li S-F, Yang H-Y, Wang L-C, Weng C-Y, Chen K-F, et al. Factors associated with cessation of exclusive breastfeeding at 1 and 2\u0026thinsp;months postpartum in Taiwan. International Breastfeeding Journal. 2019;14(1):18.\u003c/li\u003e\n\u003cli\u003eKohlhuber M, Rebhan B, Schwegler U, Koletzko B, Fromme H. Breastfeeding rates and duration in Germany: a Bavarian cohort study. British Journal of Nutrition. 2008;99(5):1127-32.\u003c/li\u003e\n\u003cli\u003ede Almeida JM, de Ara\u0026uacute;jo Barros Luz S, da Veiga Ued F. Support of breastfeeding by health professionals: integrative review of the literature. Revista Paulista de Pediatria (English Edition). 2015;33(3):355-62.\u003c/li\u003e\n\u003cli\u003eMerz C, Shield A, McClatchey A. Breastfeeding education provided to university health students: is it enough to support breastfeeding women? Research in Social and Administrative Pharmacy. 2019;15(5):e25.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization, Unicef. Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-Friendly Hospital Initiative 2018 2018 [Available from: \u003ca href=\"http://www.who.int/nutrition/publications/infantfeeding/bfhi-implementation/en/\"\u003ehttp://www.who.int/nutrition/publications/infantfeeding/bfhi-implementation/en/\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003ePramono A, Desborough J, Smith J. The Ten Steps to Successful Breastfeeding Policy Review. Breastfeeding Review. 2019;27(3):14.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Baby Friendly Hospital Initiative 2018 [Available from: \u003ca href=\"http://www.who.int/nutrition/topics/bfhi/en/\"\u003ehttp://www.who.int/nutrition/topics/bfhi/en/\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003eAustralian College of Midwives. Baby Friendly Health Initiative (BFHI) Accreditation 2018 [Available from: \u003ca href=\"https://www.midwives.org.au/baby-friendly-health-initiative-bfhi-accreditation\"\u003ehttps://www.midwives.org.au/baby-friendly-health-initiative-bfhi-accreditation\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003ePerez-Escamilla R, Martinez J, Segura-Perez S. Impact of the Baby-Friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review. Maternal and Child Nutrition. 2016;12:13.\u003c/li\u003e\n\u003cli\u003eFallon A, Crepinsek M, Hegney D, O'Brien M. The Baby-Friendly Hospital Initiative and Breastfeeding Duration: Relating the Evidence to the Australian Context2005.\u003c/li\u003e\n\u003cli\u003eBroadfoot M, Britten J, Tappin DM, MacKenzie JM. The Baby Friendly Hospital Initiative and breast feeding rates in Scotland. Arch Dis Child Fetal Neonatal Ed. 2005;90(2):F114-6.\u003c/li\u003e\n\u003cli\u003eMunn AC, Newman SD, Mueller M, Phillips SM, Taylor SN. The Impact in the United States of the Baby-Friendly Hospital Initiative on Early Infant Health and Breastfeeding Outcomes. Breastfeed Med. 2016;11:222-30.\u003c/li\u003e\n\u003cli\u003eSpaeth A, Zemp E, Merten S, Dratva J. Baby-Friendly Hospital designation has a sustained impact on continued breastfeeding. Maternal \u0026amp; Child Nutrition. 2018;14(1):e12497.\u003c/li\u003e\n\u003cli\u003eSilva OLdO, Rea MF, Sarti FM, Buccini G. Cost-effectiveness analysis of Baby-Friendly Hospital Initiative in promotion of breast-feeding and reduction of late neonatal infant mortality in Brazil. Public Health Nutrition. 2020:1-11.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. National Implementation of the Baby-Friendly Hospital Initiative 2017. 2017.\u003c/li\u003e\n\u003cli\u003eBFHI Australia. About BFHI 2020 [Available from: \u003ca href=\"https://bfhi.org.au/about/\"\u003ehttps://bfhi.org.au/about/\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization, United Nations Children's Fund (UNICEF). Compendium of Case Studies of the Baby Friendly Hospital Initiative. 2017.\u003c/li\u003e\n\u003cli\u003eAtchan M, Davis D, Foureur M. The impact of the Baby Friendly Health Initiative in the Australian health care system: a critical narrative review of the evidence. Breastfeed Rev. 2013;21(2):15-22.\u003c/li\u003e\n\u003cli\u003eAtchan M, Davis D, Foureur M. An instrumental case study examining the introduction and dissemination of the Baby Friendly Health Initiative in Australia: Participants\u0026rsquo; perspectives. Women and Birth. 2018;31(3):210-9.\u003c/li\u003e\n\u003cli\u003eAtchan M, Davis D, Foureur M. Applying a knowledge translation model to the uptake of the Baby Friendly Health Initiative in the Australian health care system. Women and Birth. 2014;27(2):79-85.\u003c/li\u003e\n\u003cli\u003eAustralian Institute of Health and Welfare. Australia's mothe and babies 2018: in brief. Canberra; 2020.\u003c/li\u003e\n\u003cli\u003eThe SROI Network. A Guide to Social Return on Investment. 2015.\u003c/li\u003e\n\u003cli\u003eChowdhury R, Sinha B, Sankar MJ, Taneja S, Bhandari N, Rollins N, et al. Breastfeeding and maternal health outcomes: a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):96-113.\u003c/li\u003e\n\u003cli\u003eCarter CM. Breastfeeding at work benefits mom, baby and the employer 2019 [Available from: \u003ca href=\"https://www.forbes.com/sites/christinecarter/2019/07/31/breastfeeding-at-work-benefits-mom-baby-and-the-employer/#29163126675f\"\u003ehttps://www.forbes.com/sites/christinecarter/2019/07/31/breastfeeding-at-work-benefits-mom-baby-and-the-employer/#29163126675f\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003eBabic A, Sasamoto N, Rosner BA, Tworoger SS, Jordan SJ, Risch HA, et al. Association Between Breastfeeding and Ovarian Cancer Risk. JAMA Oncology. 2020;6(6):e200421-e.\u003c/li\u003e\n\u003cli\u003eRanadip C, Bireshwar S, Jeeva SM, Sunita T, Nita B, Nigel R, et al. Breastfeeding and maternal health outcomes: a systematic review and meta-analysis. Acta Paediatrica. 2015;104(S467):96-113.\u003c/li\u003e\n\u003cli\u003eUnar-Mungu\u0026iacute;a M, Torres-Mej\u0026iacute;a G, Colchero MA, Gonz\u0026aacute;lez de Cos\u0026iacute;o T. Breastfeeding Mode and Risk of Breast Cancer: A Dose\u0026ndash;Response Meta-Analysis. Journal of Human Lactation. 2017;33(2):422-34.\u003c/li\u003e\n\u003cli\u003eBinns C, Lee M, Low WY. The Long-Term Public Health Benefits of Breastfeeding. Asia Pacific Journal of Public Health. 2016;28(1):7-14.\u003c/li\u003e\n\u003cli\u003eAnderson JW, Johnstone BM, Remley DT. Breast-feeding and cognitive development: a meta-analysis. Am J Clin Nutr. 1999;70(4):525-35.\u003c/li\u003e\n\u003cli\u003eFrank NM, Lynch KF, Uusitalo U, Yang J, L\u0026ouml;nnrot M, Virtanen SM, et al. The relationship between breastfeeding and reported respiratory and gastrointestinal infection rates in young children. BMC Pediatrics. 2019;19(1):339.\u003c/li\u003e\n\u003cli\u003eThompson JMD, Tanabe K, Moon RY, Mitchell EA, McGarvey C, Tappin D, et al. Duration of Breastfeeding and Risk of SIDS: An Individual Participant Data Meta-analysis. Pediatrics. 2017;140(5):e20171324.\u003c/li\u003e\n\u003cli\u003eLamberti LM, Fischer Walker CL, Noiman A, Victora C, Black RE. Breastfeeding and the risk for diarrhea morbidity and mortality. BMC Public Health. 2011;11(3):S15.\u003c/li\u003e\n\u003cli\u003eVictora CG, Horta BL, de Mola CL, Quevedo L, Pinheiro RT, Gigante DP, et al. Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil. The Lancet Global Health. 2015;3(4):e199-e205.\u003c/li\u003e\n\u003cli\u003eKrol KM, Grossmann T. Psychological effects of breastfeeding on children and mothers. Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz. 2018;61(8):977-85.\u003c/li\u003e\n\u003cli\u003eHerrmann K, Carroll K. An exclusively human milk diet reduces necrotizing enterocolitis. Breastfeed Med. 2014;9(4):184-90.\u003c/li\u003e\n\u003cli\u003eHorta BL, Loret de Mola C, Victora CG. Breastfeeding and intelligence: a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):14-9.\u003c/li\u003e\n\u003cli\u003eWoo JG, Martin LJ. Does Breastfeeding Protect Against Childhood Obesity? Moving Beyond Observational Evidence. Curr Obes Rep. 2015;4(2):207-16.\u003c/li\u003e\n\u003cli\u003eBarker SF, Zomer E, O'Toole J, Sinclair M, Gibney K, Liew D, et al. Cost of gastroenteritis in Australia: A healthcare perspective. PLoS One. 2018;13(4):e0195759.\u003c/li\u003e\n\u003cli\u003eNewall AT, Scuffham PA. Influenza-related disease: the cost to the Australian healthcare system. Vaccine. 2008;26(52):6818-23.\u003c/li\u003e\n\u003cli\u003eTaylor PS, Faeth I, Marks MK, Del Mar CB, Skull SA, Pezzullo ML, et al. Cost of treating otitis media in Australia. Expert Review of Pharmacoeconomics \u0026amp; Outcomes Research. 2009;9(2):133-41.\u003c/li\u003e\n\u003cli\u003eDrane D. Breastfeeding and formula feeding: a preliminary economic analysis. Breastfeeding Review. 1997;5(1).\u003c/li\u003e\n\u003cli\u003eHanafin S, O\u0026rsquo;Dwyer K, Creedon M, Clune Mulvaney C. Social Return on Investment: PHN-facilitated breastfeeding groups in Ireland. Research Matters Ltd; 2018.\u003c/li\u003e\n\u003cli\u003eColagiuri S, Lee CM, Colagiuri R, Magliano D, Shaw JE, Zimmet PZ, et al. The cost of overweight and obesity in Australia. Med J Aust. 2010;192(5):260-4.\u003c/li\u003e\n\u003cli\u003eLee CMY, Goode B, N\u0026oslash;rtoft E, Shaw JE, Magliano DJ, Colagiuri S. The cost of diabetes and obesity in Australia. J Med Econ. 2018;21(10):1001-5.\u003c/li\u003e\n\u003cli\u003eGoldsbury DE, Yap S, Weber MF, Veerman L, Rankin N, Banks E, et al. Health services costs for cancer care in Australia: Estimates from the 45 and Up Study. PLoS One. 2018;13(7):e0201552.\u003c/li\u003e\n\u003cli\u003eMathers C, Penm R. Health system costs of cardiovascular diseases and diabetes in Australia 1993-94. Australian Institute of Health and Welfare; 1997.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Costs and savings. 2009. In: Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care [Internet]. Geneva: World Health Organization. Available from: \u003ca href=\"https://www.ncbi.nlm.nih.gov/books/NBK153460/\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK153460/\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003eDeans J. Discount rates for Commonwealth infrastructure projects 2018 [Available from: \u003ca href=\"https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/FlagPost/2018/October/Discount-rates\"\u003ehttps://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/FlagPost/2018/October/Discount-rates\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003eGoudet S, Griffiths PL, Wainaina CW, Macharia TN, Wekesah FM, Wanjohi M, et al. Social value of a nutritional counselling and support program for breastfeeding in urban poor settings, Nairobi. BMC Public Health. 2018;18(1):424.\u003c/li\u003e\n\u003cli\u003eHutchinson CL, Berndt A, Forsythe D, Gilbert-Hunt S, George S, Ratcliffe J. Valuing the impact of health and social care programs using social return on investment analysis: how have academics advanced the methodology? A systematic review. BMJ Open. 2019;9(8):e029789.\u003c/li\u003e\n\u003cli\u003eWalters DD, Phan LTH, Mathisen R. The cost of not breastfeeding: global results from a new tool. Health Policy and Planning. 2019.\u003c/li\u003e\n\u003cli\u003eSmith JP, Thompson JF, Ellwood DA. Hospital system costs of artificial infant feeding: estimates for the Australian Capital Territory. Aust N Z J Public Health. 2002;26(6):543-51.\u003c/li\u003e\n\u003cli\u003eColaizy T, Bartick M, Jegier B, Brittany, Green D, Reinhold AG, et al., editors. Impact of suboptimal breastfeeding on the healthcare and mortality costs of necrotizing enterocolitis in extremely low birthweight infants2017.\u003c/li\u003e\n\u003cli\u003eHamelmann C, Turatto F, Then V, Dyakova M. Social return on investment: accounting for value in the context of implementing Health 2020 and the 2030 Agenda for Sustainable Development. In: Europe WHOROf, editor. Investment for health and development discussion paper. Copenhagen2017.\u003c/li\u003e\n\u003cli\u003eLutter CK, Chaparro CM, Grummer-Strawn LM. Increases in breastfeeding in Latin America and the Caribbean: an analysis of equity. Health Policy and Planning. 2010;26(3):257-65.\u003c/li\u003e\n\u003cli\u003eSmith JP. \u0026ldquo;Lost Milk?\u0026rdquo;:Counting the Economic Value of Breast Milk in Gross Domestic Product. Journal of Human Lactation. 2013;29(4):537-46.\u003c/li\u003e\n\u003cli\u003eRobertson A. Breastfeeding initiation at birth can help reduce health inequalities. In: WHO Collaborating Centre in Global Nutrition and Health, editor. Denmark2015.\u003c/li\u003e\n\u003cli\u003eAustralian Institute of Health and Welfare. Australia's Health 2018. 2018.\u003c/li\u003e\n\u003cli\u003eMcLachlan HL, Shafiei T, Forster DA. Breastfeeding initiation for Aboriginal and Torres Strait Islander women in Victoria: analysis of routinely collected population-based data. Women and Birth. 2017;30(5):361-6.\u003c/li\u003e\n\u003cli\u003eStanding Committee on Health and Ageing. The Best Start: Report on the inquiry into the health benefits of breastfeeding. Canberra, Australia: Commonwealth of Australia; 2007.\u003c/li\u003e\n\u003cli\u003eMerten S, Dratva J, Ackermann-Liebrich U. Do baby-friendly hospitals influence breastfeeding duration on a national level? Pediatrics. 2005;116(5):e702-8.\u003c/li\u003e\n\u003cli\u003eVehling L, Chan D, McGavock J, Becker AB, Subbarao P, Moraes TJ, et al. Exclusive breastfeeding in hospital predicts longer breastfeeding duration in Canada: Implications for health equity. Birth. 2018;45(4):440-9.\u003c/li\u003e\n\u003cli\u003eCommonwealth Department of Health and Aged Care. National Breastfeeding Strategy summary report. In: Care DoHaA, editor. Canberra, ACT.: Commonwealth of Australia; 2001.\u003c/li\u003e\n\u003cli\u003eAustralian Health Ministers' Conference. 2010 Implementation Plan for the Australian National Breastfeeding Strategy 2010-2015. In: Health Do, editor. Canberra, Australia: Australian Government Department of Health; 2010.\u003c/li\u003e\n\u003cli\u003eState of Victoria Department of Health and Human Services. Maternal and Child Health Services guidelines. In: Department of Health and Human Services, editor. 2019.\u003c/li\u003e\n\u003cli\u003eWestern Australia Country Health Service. WA Country Health Service Maternal and Newborn Care Strategy 2019-2024. Western Australia2018.\u003c/li\u003e\n\u003cli\u003eNSW Government. Breastfeeding in NSW - Promotion, Protection and Support. In: Ageing DoHa, editor. New South Wales2018.\u003c/li\u003e\n\u003cli\u003eCOAG Health Council. Australian National Breastfeeding Strategy 2019 and beyond. 2019.\u003c/li\u003e\n\u003cli\u003eSmith JP, Forrester R. Who pays for the health benefits of exclusive breastfeeding? An analysis of maternal time costs. J Hum Lact. 2013;29(4):547-55.\u003c/li\u003e\n\u003cli\u003eSmith JP, Forrester R. Maternal Time Use and Nurturing: Analysis of the Association Between Breastfeeding Practice and Time Spent Interacting with Baby. Breastfeeding Medicine. 2017.\u003c/li\u003e\n\u003cli\u003eJegier BJ, Meier P, Engstrom JL, McBride T. The initial maternal cost of providing 100 mL of human milk for very low birth weight infants in the neonatal intensive care unit. Breastfeeding Medicine. 2010;5(2):71-7.\u003c/li\u003e\n\u003cli\u003eTrickey H, Thomson G, Grant A, Sanders J, Mann M, Murphy S, et al. A realist review of one‐to‐one breastfeeding peer support experiments conducted in developed country settings. Maternal \u0026amp; Child Nutrition. 2018;14(1).\u003c/li\u003e\n\u003cli\u003eForster DA, McLardie-Hore FE, McLachlan HL, Davey M-A, Grimes HA, Dennis C-L, et al. Proactive Peer (Mother-to-Mother) Breastfeeding Support by Telephone (Ringing up About Breastfeeding Early [RUBY]): A Multicentre, Unblinded, Randomised Controlled Trial. EClinicalMedicine. 2019;8:20-8.\u003c/li\u003e\n\u003cli\u003eSchmied V, Burns E, Sheehan A. Place of sanctuary: an appreciative inquiry approach to discovering how communities support breastfeeding and parenting. International Breastfeeding Journal. 2019;14(1):25.\u003c/li\u003e\n\u003cli\u003eAustralian Government Fair Work Ombudsman. Pay Guide - Nurses Award. 2020.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Social Value, Breastfeeding, Investment (SROI), World Health Organization (WHO)","lastPublishedDoi":"10.21203/rs.3.rs-97226/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-97226/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\u003cp\u003eBreastfeeding has positive impacts on the health, environment, and economic wealth of families and countries. Nevertheless, barriers to accessing high-quality breastfeeding support are evident in the low global exclusive breastfeeding rate of 41%. The World Health Organization (WHO) launched the Baby Friendly Hospital Initiative (BFHI) in 1991 as a global program to incentivize maternity services to implement the Ten Steps to Successful Breastfeeding (Ten Steps). These were developed to ensure that maternity services remove barriers for mothers and families to successfully initiate breastfeeding and to continue breastfeeding through referral to community support after hospital discharge. However, in 2020 only 26% of Australian hospitals were BFHI-accredited. This study aimed to examine the social return on investment (SROI) of implementing the BFHI in one public maternity unit in Australia.\u003c/p\u003e\u003cp\u003eMethod\u003c/p\u003e\u003cp\u003eThe study was non-experimental and conducted in the maternity unit of an Australian BFHI-accredited public hospital with around 1000 births annually. This facility illustrated costs for BFHI implementation in a relatively affluent urban population, and more than three in four births in Australia take place in public hospitals. \u0026nbsp;Stakeholders considered within scope of the study were the mother-baby dyad and the maternity facility. We interviewed the hospital’s Director of Maternity Services and the Clinical Midwifery Educator, guided by a structured questionnaire, which examined the cost (financial, time and other resources) and benefits of each of the Ten Steps. Analysis was informed by the Social Return on Investment (SROI) framework, which uses monetary values to measure social, environmental and economic outcomes of change. This information was supplemented with micro costing studies from the literature that measure the benefits of the BFHI. \u003c/p\u003e\u003cp\u003eResults\u003c/p\u003e\u003cp\u003eThe social return from the BFHI initiative in this facility was calculated to be AU$ 1,398,140. The total investment required was AU$ 24,433 per year. Therefore, the SROI ratio was approximately AU$ 55:1 (sensitivity analysis: AU$ 16-112), which meant that every AU$1 invested in BFHI implementation by this maternal and newborn care facility generated approximately AU$55 of benefit. \u003c/p\u003e\u003cp\u003eConclusions\u003c/p\u003e\u003cp\u003eScaled up nationally, the BFHI could provide important benefits to the Australian health system and national economy. In this public hospital, the BFHI produced social value greater than the cost of investment, providing new evidence of its effectiveness and economic gains as a public health intervention. Our findings using a novel tool to calculate the social rate of return, indicate that implementation of the BHFI is an investment in the health and wellbeing of families, communities and the Australian economy, as well as in health equity.\u003c/p\u003e","manuscriptTitle":"Social Value of Baby-Friendly Hospital Initiative Implementation in Australia: Case Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-10-28 21:57:11","doi":"10.21203/rs.3.rs-97226/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2020-11-13T00:00:00+00:00","index":2,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"decision","content":"Major Revision","date":"2020-11-13T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-11-03T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"reviewerAgreed","content":"","date":"2020-10-24T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-10-21T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-10-20T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-10-20T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-10-19T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-10-19T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-10-18T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"02900843-b8f3-49be-a8da-5a4cf95d2712","owner":[],"postedDate":"October 28th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":908765,"name":"Health Policy"}],"tags":[],"updatedAt":"2021-01-10T15:06:05+00:00","versionOfRecord":{"articleIdentity":"rs-97226","link":"https://doi.org/10.1186/s12939-020-01365-3","journal":{"identity":"international-journal-for-equity-in-health","isVorOnly":false,"title":"International Journal for Equity in Health"},"publishedOn":"2021-01-07 15:03:00","publishedOnDateReadable":"January 7th, 2021"},"versionCreatedAt":"2020-10-28 21:57:11","video":"","vorDoi":"10.1186/s12939-020-01365-3","vorDoiUrl":"https://doi.org/10.1186/s12939-020-01365-3","workflowStages":[]},"version":"v1","identity":"rs-97226","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-97226","identity":"rs-97226","version":["v1"]},"buildId":"wLkW0s4AflPzk-lpfg-fK","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}