Objectives To examine compliance with the Baby-Friendly Hospital Initiative (BFHI) as well as evaluate the BFHI and its components on breastfeeding initiation and duration overall and according to maternal education level.

Design Quasi-experimental study using data from the Pregnancy Risk Assessment Monitoring System (PRAMS) from 2004 to 2008.

Setting Birth facilities in Maine.

Participants 915 mothers who gave birth in four hospitals that were BFHI-accredited or became accredited and 1099 mothers from six matched non-BFHI facilities. Mothers reported on seven (of 10) BFHI practices (breastfeeding practice score 0–7) and receipt of a gift pack with formula (yes/no).

Main outcome measures Self-report of breastfeeding initiation, any breast feeding for ≥4 weeks, exclusive breast feeding for ≥4 weeks.

Results 34.6% of mothers from BFHI-accredited facilities reported experiencing all seven BFHI breastfeeding practices, while 28.4% reported being given a gift pack with formula. Among mothers with lower education, the BFHI increased breastfeeding initiation by 8.6 percentage points (adjusted coefficient, 0.086 [95% CI, 0.01 to 0.16]) and, independently, each additional breastfeeding practice was associated with an average increase in breastfeeding initiation of 16.2 percentage points (adjusted coefficient, 0.162 [95% CI, 0.15 to 0.18]). Among all mothers and mothers with higher education, there was no effect of the BFHI on breastfeeding rates.

Conclusions Compliance with BFHI practices among BFHI-accredited facilities is not optimal and needs to be monitored, as greater compliance may have an even larger impact on breastfeeding rates and potentially reduce socio-economic disparities in breast feeding.