THE BABY FRIENDLY HOSPITAL INITIATIVE

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.”

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 2012 95% 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.

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

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. 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

18. 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

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 staff100% 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 exclusivebreastfeeding for 6 months - The importance of breastfeeding - Basic breastfeeding management - Breastfeeding support in the community

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

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