Getting Started

Your facility can make a commitment to improve infant feeding policies, training and practices by embarking on the 4-D Pathway to Baby-Friendly Designation. This program was designed to aid facilities in achieving the world-class Baby-Friendly® designation.  The method maintains all of the high standards set by a team of global experts, while breaking the process down into manageable and achievable phases. Following the 4-D Pathway will assist facilities with implementation of the  Baby-Friendly principles in a logical and efficient manner.  The journey creates an environment that is supportive of best practices in maternity care for optimal infant feeding.

The 4-D Pathway is fit for all institutions; large and small hospitals, for profit and not-for-profit hospitals, teaching hospitals, and hospitals at various stages of development in their breastfeeding education and support services, as well as birthing centers.

Facilities providing maternity care throughout the US and US Territories may earn the Baby-Friendly designation by successfully completing all 4 phases of the 4-D Pathway, implementing the Guidelines and Evaluation Criteria and passing an on-site assessment. The Baby-Friendly designation process requires verification of policies, curriculum, action plans, quality improvement projects, staff training, and competency verification, as well as a readiness interview and an on-site survey. Upon successful completion of this process, as determined by the onsite assessment, the facility will be granted a license to use the Baby-Friendly certification mark.

What Are the Steps in the 4-D Pathway?

The 4-D Pathway is a tool for facilities to use to measure their progress along the journey that leads to Baby-Friendly designation. To achieve the Baby-Friendly designation, facilities first register with Baby-Friendly USA. They then complete all of the requirements in each of the four phases of the process. Ultimately, the facility demonstrates that they have attained the gold standard of maternity practices that support optimal infant nutrition during an on-site assessment. At the on-site assessment, the facility must demonstrate to Baby-Friendly USA assessors that they have correctly integrated all of the Ten Steps To Successful Breastfeeding and the International Code of Marketing of Breast-milk Substitutes into their maternity practices. The Baby-Friendly USA Guidelines and Evaluation Criteria detail the specific benchmarks against which birthing facilities will be held during their on-site assessment.

Baby-Friendly USA 4D Pathway to Designation - Updated 2019

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The four phases in the 4-D pathway are:

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The “Learning Phase”

Your facility will submit a two-part registration form to BFUSA, understand what it means to be a Baby-Friendly designated facility, and learn what it takes to achieve designation.

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D2: Development

The “Planning Phase”

Your facility will make a commitment to the process and receive a comprehensive online toolkit to create and submit your plan for achieving Baby-Friendly guidelines.

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D3: Dissemination

“Implementing Phase”

Your facility will implement the plan established in the Development Phase and continue quality improvement activities until all required standards are met.

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D4: Designation

The “Assessing Phase”

Having completed implementation, your facility will discuss your readiness with BFUSA in a telephone interview and then invite BFUSA to conduct an on-site assessment.

Two phases are required to maintain designation:

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Annual QI

Annual QI

To ensure continued compliance with BFUSA guidelines, facilities are required to complete an Annual Quality Improvement project.



Your Baby-Friendly designation will expire after five years, at which time your facility will enter the BFUSA re-designation process.