THE BABY FRIENDLY HOSPITAL INITIATIVE

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THE BABY FRIENDLY HOSPITAL INITIATIVE

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• 1981
• The World Health Organizations (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)

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1989 The Ten Steps to Successful
Breastfeeding

• A joint WHO/UNICEF statement from
• Protecting, Promoting and Supporting
  Breastfeeding The Special Role of Maternity
  Services.

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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.

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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

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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 2012 95 of all facilities in New Zealand are
  BFHI accreditted

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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.

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• 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

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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

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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

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

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

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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.

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• 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.

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• 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.

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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

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• 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

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• 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

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The Ten Steps to Successful BreastfeedingHELPFU
L ADVICE
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Step One Have a written breastfeeding
policy that is routinely communicated to all
health-care staff100 compliance required for
this step
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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

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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

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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!

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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 gt5 of clientele

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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

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

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• If you think
• education is expensive,
• try ignorance

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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

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• 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.

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• 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
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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

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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

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• 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.

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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

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Suggested education methods

• Study days
• On-line education
• Worksheets
• Videos/DVDs with questionnaires
• Research papers with questionnaire
• Case studies/presentations
• Discussion periods

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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

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Awareness Level

• This could include
• Hospital aides
• Cleaners
• Physiotherapists
• General theatre staff
• Receptionists
• Dietitians
• Anaesthetists

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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

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• 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

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Knowledge will

• Prevent conflict
• Motivate staff

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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

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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

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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

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• Step Four Help mothers initiate breastfeeding
  within a half an hour of birth

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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

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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

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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

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

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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

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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

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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

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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.

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.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

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

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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

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Why?

• Reduces costs
• Requires minimal equipment
• Requires no additional personnel
• Reduces infection
• Helps establish and maintain breastfeeding
• Facilitates the bonding process

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Mothers should be told

• The importance of rooming-in for baby/mother and
  breastfeeding
• Babys cues for feeding crying is the last
  cue!!
• More breastfeeds
• Longer breastfeeding duration
• Prevents infection
• Safety factors
• Safe and unsafe sleep practices

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• 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

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• Step Eight Encourage breastfeeding on demand

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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

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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

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

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• 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

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

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Reasons include

• These can interfere with the suckling action
• Upsets the needs of the baby ? decreased
  stimulation of the breast
• Disempowerment of the mother

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• 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

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

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• The key to best breastfeeding practices is
  continued day-to-day support for the
  breastfeeding mother within her home and
  community

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• 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

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• 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

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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.

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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

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• 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

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References

• The BFHI Documents for Aotearoa New Zealand
  (2011)
• International Code of Marketing of Breastmilk
  Substitutes and Relevant WHA resolutions IBFAN
  2006