1. THE BABY FRIENDLY HOSPITAL INITIATIVE

2. 1981:
The World Health Organization’s (WHO) International Code of Marketing of
Breast-milk Substitutes, adopted by the World Health Assembly, is a comprehensive set of guidelines, for those who work and interact with mothers and babies, that offers standards for the appropriate marketing and distribution of commercial competitors to breastfeeding
(i.e. makers of infant formula)

3. 1989: The “Ten Steps to Successful Breastfeeding”
A joint WHO/UNICEF statement from
“Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services.”
The Ten Steps were adopted in 1989

4. 1990: World Summit for Children Statement:
Empowerment of all women to exclusively breastfeed their children for four to six months and to continue breastfeeding, with complementary food, well into the second year.
Exclusive breastfeeding for six months is the ‘gold standard’ for optimal health.

5. 1991: The launch of the BFHI
The WHO/UNICEF International Code of Marketing of Breast-milk Substitutes (and subsequent relevant World Health Assembly resolutions)
The Ten Steps to Successful Breastfeeding

6. In New Zealand:
BFHI launched World Breastfeeding Week 2000 (August 1st – 7th)
First hospitals BFHI accredited 2002
The Treaty of Waitangi is an integral part of BFHI in Aotearoa New Zealand
Government wanted all maternity facilities to be accredited by the end of 2005!
By % of all facilities in New Zealand are BFHI accreditted

7. BFHI: A Standard of Care
Supports the breastfeeding dyad
In New Zealand 95% of women give birth intending to breastfeed.
Does not mean facilities do not support the woman who has decided to formula feed her baby.
95% initiate breastfeeding – data extrapolated from breastfeeding statistics received from BFHI assessments of over 90% of facilities in New Zealand (2010)

8. Basic principles are non-negotiable
Minimum standard of maternity practice
Random sample of mothers must be interviewed
Random sample of all levels of staff
Antenatal and maternity service practice must be observed

9. In New Zealand to meet the BFHI standards:
A facility must
have had an exclusive breastfeeding rate of over 75% on discharge, for the past year
Gain 100% for Steps 1 and 7
Attain a minimum of 80% for all other questions, in all the other standards of the assessment

10. WHO/UNICEF International Code of Marketing of Breast-milk Substitutes
No advertising of breastmilk substitutes in the health care system or to the public
No free samples to be given to mothers or pregnant women
No free or subsidised supplies to hospitals
No contact between company marketing personnel and mothers
The Main Points of The Code

11. Materials for mothers should be non-promotional and should carry clear and full information and warnings.
Companies should not give gifts to health workers
No free samples to health workers, except for professional evaluation or research at the institutional level

12. Materials for health workers should contain only scientific and factual information.
No pictures of babies or other idealising images on infant formula labels.
The labels of other products must provide the information needed for appropriate use, so as not to discourage breastfeeding.

13. Every facility providing maternity services and care for newborn infants should:
1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within a half-hour of birth.

14. 5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
6. Give newborn infants no food or drink unless medically indicated.
7. Practise rooming-in – allow mothers and infants to remain together – 24 hours a day.
8. Encourage breastfeeding on demand.

15. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

16. THINGS TO DO: For ‘the Code’
Have a Policy to cover The Code?
Include a policy for formula company representatives – in keeping with the Code of Marketing?
Include a policy for appropriate management of formula – alternating brands regularly, ensuring the cost paid for the formula is at least 80% of the retail price?
Ensure formula tins are out of view – no labels seen
Bottles and teats are stored out of view
No references to bottles and teats

17. Always remember breastfeeding is the normal
Is there a policy requesting that women who choose to A/F bring in own formula
Always remember breastfeeding is the normal
Toys in toy boxes – yes - they also need to be Code compliant
Books in the units do not contain information which violate the Code
Diaries, lanyards have not been gifted to staff
Consent for formula – in appropriate languages
Formula purchase records – need to be available – showing a decrease in use!
Check “gift bags” are Code compliant
Can request mothers bring their own formula – the one they intend to continue using – however this cannot be enforced if mother refuses

18. Check A/N references and handouts are also Code compliant
Check posters comply
Check pamphlets given out to mothers are not advertising anything found under the scope of the Code
Check A/N references and handouts are also Code compliant
The scope of the “Code applies to the marketing, and practices related thereto, of the following products: breastmilk substitutes, including infant formula; other milk products, foods and beverages, including bottle-fed complementary foods, when marketed or otherwise to be suitable, with or without modification, for use as a partial or total replacement of breastmilk; feeding bottles and teats. It also applies to their quality and availability and to information concerning their use.” International Code of Marketing of Breastmilk Substitutes and Relevant WHA resolutions IBFAN 2006

19. The Ten Steps to Successful Breastfeeding: HELPFUL ADVICE

20. Step One: Have a written breastfeeding policy that is routinely communicated to all health-care staff 100% compliance required for this step

21. Breastfeeding Policy Why have a Policy?
Requires a course of action and provides guidance
Helps establish consistent care for mothers and babies
Provides a standard that can be evaluated

22. The Breastfeeding Policy:
What should it cover?
At minimum it must include:
The 10 Steps to Successful Breastfeeding
An institutional ban on acceptance of free or low cost supplies of breastmilk substitutes, bottles and teats
- The facility must work in allegiance to the Treaty of Waitangi to improve outcomes for Maori and non-Maori in their community

23. The Policy…………….. Must be visible Must be in appropriate languages.
Should be available on request.
Recognise it as a wonderful tool for women and staff – powerful and empowering!

24. Consultation for the Policy:
Must be seen – good paper trail essential
Must be wide consultation process!
Must include consultation with Maori and any culture represented by >5% of clientele

25. The Policy…………………… Sign-off date noted Displayed in all areas
Translated into relevant languages
Included in the orientation for all new staff
Other policies should be seen to support the policy eg: hypoglycaemia
Evaluation tool available to assess effectiveness of policy – audit against the Policy

26. Step 2: Train all health care staff in skills necessary to implement this policy.

27. “ If you think
education is expensive,
try ignorance”

28. Education
Includes NICU staff and any staff that come in contact with breastfeeding mothers and babies
Hours required vary
Records must be clear and available
Education must be seen to be ongoing
Documentation of all education taught, and their programmes, should be available to view

29. Staff employed within the past 6 months must have been orientated to the Breastfeeding Policy and been placed on the next available breastfeeding education session - but are not included in the overall percentage of staff required to meet this step at the assessment.

30. Facility staff are required to have prescribed amounts of education.
Specialist Level – 21hrs (and the equivalent to 4hrs annually ongoing)
Generalist Level – the equivalent to 2hrs for each year of employment – assessed over the previous three years (and the equivalent to 2hrs annually ongoing)
Awareness Level – the equivalent to 1hr for each year of employment assessed over the previous three years (and the equivalent to 1hr annually ongoing)
Breastfeeding

31. Staff who assist with breastfeeding:
may include midwives, nurses and hospital aides (in some cases)
at least 80% of these staff are required to have had a minimum of 21 hours education at the time of assessment
ongoing education must equate to a minimum of 4 hours annually
stipulated components including ‘Breastfeeding for Maori Women’ and clinical education

32. Documentation must show:
For each individual staff member the date of:
Commencement of employment
Orientation to the Breastfeeding Policy at commencement of employment and whenever the policy is reviewed

33. Completion of 3 hours (minimum) supervised clinical education
Further relevant breastfeeding education sessions (with hours/programmes/sign-on sheets)
= total of 21 hours minimum breastfeeding education which indicates an ongoing education programme is in place.

34. Areas of knowledge: Hospital breastfeeding policies and practices
The basic components of BFHI
The importance of breastfeeding
Risks of artificial feeding
Mechanisms of lactation and suckling
How to help mothers initiate and sustain breastfeeding
How to assess a breastfeed
How to resolve common breastfeeding difficulties

35. Suggested education methods:
Study days
On-line education
Worksheets
Videos/DVD’s with questionnaires
Research papers with questionnaire
Case studies/presentations
Discussion periods

36. Generalist Level: Documentation which shows the date: Of employment
Orientation to the Breastfeeding Policy
Breastfeeding education received which must include ‘The Ten Steps’ and ‘The Code’
Ongoing education
80% must have completed the above – equating to a minimum of 2 hours for each year of employment, assessed over the previous three years. Ongoing education equates to a minimum of 2 hours annually

37. Awareness Level This could include: Hospital aides Cleaners
Physiotherapists
General theatre staff
Receptionists
Dietitians
Anaesthetists

38. Education requirement:
These staff are required to have had
three hours of breastfeeding education over
the previous three years or (if employed within the
previous three years) the equivalent of one
hour for each year since employment.
This education must include:
the Ten Steps to Successful Breastfeeding
the protection of breastfeeding (the ‘Code’)
Ongoing education: must equate to a minimum of
one hour annually

39. If the first two steps have been well advanced and staff have all had the education and understand the Policy then the rest of the “Ten Steps” and compliance with “The Code” should follow-on

40. Knowledge will:
Prevent conflict
Motivate staff

41. Step Three: ANTENATAL EDUCATION
Written documentation of content of classes
Needs to Cover:
- The Breastfeeding Policy
- The importance of exclusive breastfeeding for 6 months
- The importance of breastfeeding
- Basic breastfeeding management
- Breastfeeding support in the community
The Breastfeeding Policy is a powerful tool – if mothers are aware of the care which should be afforded to them.
Breastfeeding as opposed to expressed breastmilk given in a bottle.

42. Continued……….. Women should have had discussed with them:
Optimal nutrition for the baby
Bonding
Protection, including the role of colostrum
Health advantages to the mother
Positioning and attachment
Importance of baby-led feeding
Importance of ‘rooming-in’, safe and unsafe sleep practices
How to ensure they have enough milk
The effect drugs given during labour and birth can have on breastfeeding

43. Antenatal information:
Explore the A/N programme
Include all women not just primiparous women
Document time when education occurred
Ensure the ‘10 steps’ are covered
Check the word ‘exclusive’ is used
Ensure women who have had previous breastfeeding issues are referred for consultation prior to birth of new baby

44. Step Four: Help mothers initiate breastfeeding within a half an hour of birth

45. New Interpretation:
Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour and encourage mothers to recognise when their babies are ready to breastfeed, offering help if necessary

46. Early initiation of breastfeeding for the well newborn
How?
Keep mother and baby together
Place baby on mothers chest
Let baby start suckling when ready
Do not hurry or interrupt the process

47. Early Initiation: Skin-to-skin contact– not blanket to skin!
Lead Maternity Carers have had policy consultation – so should comply
Assistance with initial breastfeed if required
Skin-to-skin contact can be discontinued once baby has latched and suckled effectively at the breast

48. Step Five: Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants

49. Step Five: Show mothers how to breastfeed……
Ensure staff can demonstrate correct positioning and latching
Mothers must be taught how to hand express
Mothers must be taught – use words!
Mothers need to know how to store milk and how often to express
Some people feel these things are not all required to be shown to a new mother – but if the woman gets home and has issues with breastfeeding (and her LMC is unavailable) at least she will have the skills to hand express (and store her milk) thereby preventing the risk of formula use and decreasing lactation. A BFHI accredited facility must show it is protecting breastfeeding (exclusive breastfeeding) – therefore this information is essential to be relayed!

50. Step Six: ONLY BREASTMILK UNLESS MEDICALLY INDICATED
In New Zealand we use the words:
‘for sound clinical reasons’
No promotion of formula
No advertising
No written handouts
Remember breastfeeding is the norm!
Formula is a treatment where breastmilk is unavailable

51. Remember: BFHI is all about the well baby!
The 20% leeway in this step allows for:
Mothers who have decided to formula feed
Babies on the postnatal ward who have required formula for a sound clinical reason

52. Sound Clinical Indication:
“There are rare exceptions during which the infant may require other food or fluids in addition to, or in place of, breastmilk. The feeding programme of these babies should be determined by qualified health professionals on an individual basis.”

53. …….unless clinically indicated
Consent for formula for breastfed babies
Check sound clinical indicators in your policy
How is expressed breastmilk/formula given to the baby – the use of bottles and teats do not support, protect or promote breastfeeding

54. Step Seven: Practice Rooming-in: Allow mothers and infants to remain together 24 hours a day

55. Rooming-in
A hospital arrangement where a mother/baby pair stay together in the same room day and night, allowing unlimited contact between mother and infant

56. Why? Reduces costs Requires minimal equipment
Requires no additional personnel
Reduces infection
Helps establish and maintain breastfeeding
Facilitates the bonding process

57. Mothers should be told:
The importance of rooming-in for baby/mother and breastfeeding
Baby’s cues for feeding – crying is the last cue!!
More breastfeeds
Longer breastfeeding duration
Prevents infection
Safety factors
Safe and unsafe sleep practices

58. Check babies are not removed from mothers room at night
Remember mothers are asked whether the baby was taken out of the room – and who initiated that separation!
Check babies are not removed from mothers room at night
100% compliance is required for this step
Babies may be separated from their mother for periods of up to an hour for a sound clinical reason; if separation is requested the mother must have requested it. If otherwise initiated the baby needs to be held during the separation (by staff or family member) for the time it is away from its mother.

59. Step Eight: Encourage breastfeeding on demand

60. Breastfeeding “on demand”
= Baby-led or cue-based feeding
= Breastfeeding whenever the baby or the mother wants, with no restrictions on the length or frequency of feeds

61. On demand, unrestricted breastfeeding
Why?
Earlier passage of meconium
Lower maximal weight loss
Breastmilk flow established sooner
Larger volume of milk intake on Day 3
Less jaundice

62. Recognise the cues
No timing
Recognise different breast capacities!
Different metabolic rates!
All women are different
All breasts are different

63. Questions asked at assessment:
Mothers are asked the cues to feed
Ensure baby-led feeding was recommended!
Know to wake baby if breasts are full (or express if this is not appropriate!)
Recognise baby is feeding effectively – milk transfer occurring

64. Step Nine:
Give no artificial teats or
pacifiers (also called dummies
or soothers) to breastfeeding
infants.

65. Reasons include: These can interfere with the suckling action
Upsets the needs of the baby  decreased stimulation of the breast
Disempowerment of the mother

66. No advertising
No discussion unless the mother has decided to formula feed – then on a one-to-one basis only
The use of pacifiers is detrimental to breastfeeding

67. Step Ten:
Foster the establishment of
breastfeeding support groups
and refer mothers to them on
discharge from the hospital or
clinic.

68. “The key to best breastfeeding practices is continued day-to-day support for the breastfeeding mother within her home and community”

69. Very important step
Discussion and handouts – find out your local groups.
Culturally appropriate
Include partners in all discussions – his/her support is paramount
Significant other and mothers very important

70. Support can include:
Early post natal or clinic check-up
Home visits
Telephone calls
Community services
Outpatient breastfeeding clinics
Peer counselling programmes
Mother support groups
Help set up new groups
Family support system

71. BFI and the Treaty of Waitangi
Facilities are assessed by a Maori assessor to ensure it works in allegiance to the Treaty of Waitangi to improve outcomes for Maori and non-Maori in the community.
The Policies, staff education and practices and observations need to met the BFHI standards.

72. Standards of care for the non-breastfeeding mother and her baby
Areas to be assessed:
The Artificial Feeding Policy
Staff education
Education of mothers on an individual basis
Post natal care ensures skin-to-skin contact and rooming-in

73. These mothers are taught how to safely prepare and feed their babies and how to clean and sterilise their feeding equipment
These mothers are taught how to manage their breasts should they become uncomfortable
All handouts are Code compliant
Safe and unsafe sleep practices are discussed

74. References: The BFHI Documents for Aotearoa New Zealand (2011)
“International Code of Marketing of Breastmilk Substitutes and Relevant WHA resolutions” IBFAN 2006