The Baby Friendly Hospital Initiative launched by United Nations Children's Fund (UNICEF) and the World Health Organization (WHO) in 1993 has become the world's largest focused accreditation program, with over 19,000 hospitals in 150 countries certified as having complied with the "Ten Steps to Successful Breastfeeding." Yet, for all its success, the initiative is having problems with sustainability. Too frequently, well-trained staff move on, hospitals lose their initial enthusiasm and commitment, and hospitals that once met certification standards no longer do so. However, the Mother and Baby Friendly Health Units Initiative (MBFHI) in Nicaragua, a program of the Ministry of Health in cooperation with UNICEF, appears to be the exception. A 1999 study documented its growth and increasing impact. The present study by the Quality Assurance Project and UNICEF/ Nicaragua sought answers to the following questions: Have the positive trends documented in 1999 been sustained? Has the program continued to grow to additional health centers, posts, and municipalities? What factors contributed to MBFHI's success? (excerpt)