Baby-friendly Initiatives in Canada and integrated Ten Steps for hospitals and community centers

1. Baby-friendly Initiatives in Canadaand integrated Ten Stepsfor hospitals and community centers Louise Dumas, RN, MSN, PhD BFI Lead assessor (BCC-WHO/UNICEF)

2. Plan of this presentation • Brief review of « Baby-Friendly Initiatives » • 2010 Integrated Ten Steps in Canada • Scientific evidences for the Ten Steps and Code • Remaining challenges in Canada

3. Brief review of « Baby-Friendly Initiatives » • Better understand…better intervene… • BFHI… WHO/UNICEF (1989+) • Canadian launching in 1998 under BFI to respect Canadian continuum of care • The Seven Point Plan for community health centers (adapting it from UK in 2004)

4. BFI = best known strategy and health care quality program • to increase breastfeeding rates • to get perinatal practices based on evidences

5. Philosophy and guiding principles Baby-Friendly Initiatives • Address needs of all mothers, breastfeeding or not • Work into empowering all mothers • Promote informed decision making by mothers • Recognize perinatal practices based on scientific evidences • Ensure seamless continuum of care and services • Stress collaboration and networking between all concerned In order to bring sustainable changes

6. For any health institution in Canada, same criteria for BFI recognition • Respect of the Ten Steps • Respect of the Code • Breastfeeding statistics showing at least 75% exclusive breastfeeding (at discharge; at entry of service) • Positive certification process

7. As per September 2010 In Canada, sincelaunching in 1998, • 11 hospitals • 3 birthing homes • 19 communityhealthcenters

8. 2010 Integrated Ten Steps in Canada: why the change? • New documents from WHO/UNICEF in 2006 • Interpretation of some steps have changed (not wording) • Removing the Seven Point Plan in Canada • Tools being united to reflect the continuum of care and to make the assessment process simpler • WHO/UNICEF’s opening to more than institutions • Canadian wording to reflect Canadian experiences

9. 2010 Integrated Ten Steps in Canada • Format: - official WHO/UNICEF wording - WHO/UNICEF’s new interpretation - wording and interpretation in Canada for hospitals and community centers • What are indicators for? To come • Appendices... to come

10. Step 1: Have a written breastfeeding policy that is routinely communicated to all health care staff Canadian interpretation: Have a written breastfeeding policy that is routinely communicated to all health care providers and volunteers

11. Step 2: Train all health care staff in the skills necessary to implement the policy Canadian interpretation: Ensure all health care providers have the knowledge and skills necessary to implement the breastfeeding policy

12. Step 3: Inform all pregnant women about the benefits and management of breastfeeding Canadian interpretation: Inform pregnant women and their families about the importance and process of breastfeeding

13. Step 4: Help mothers initiate breastfeeding within a half-hour of birth Canadian interpretation: Place babies in skin-to-skin contact with their mothers immediately following birth for at least one hour or until completion of the first feeding or as long as the mother wishes: encourage mothers to recognize when their babies are ready to breastfeed and offer help if needed For babies born vaginally and by cesarean section without general anesthesia

14. Step 5: Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants Canadian interpretation: Assist mothers to breastfeed and maintain lactation should they face challenges such as separation from their infants. This step encompasses 3 circumstances: • Initiation/establishment of bf when mother/baby are rooming-in • Initiation/establishment of lactation if mother/baby separated • Anticipatory guidance for mothers in hospitals and community

15. Step 6: Give newborns no food or drink other than breastmilk, unless medically indicated Canadian interpretation: Infants are not offered food or drink other than human milk for the first 6 months, unless medically indicated

16. Step 7: Practice rooming-in-allow mothers and infants to remain together 24 hrs a day Canadian interpretation: Facilitate 24 hour rooming-in for all mothers : mothers and infants remain together

17. Step 8: Encourage breastfeeding on demand Canadian interpretation: • Encourage baby-led or cue-based breastfeeding. • Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods.

18. Step 9: Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants Canadian interpretation: Support mothers to feed and care for their breastfeeding babies without the use of artificial teats or pacifiers (dummies or soothers).

19. Step 10: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic Canadian interpretation: Provide a seamless transition between the services provided by the hospital, the community health services, and peer support programs.

20. Compliance with the International Code of Marketing of Breastmilk Substitutes Canadian interpretation: • No free products • Purchase of substitutes and related supplies for the wholesale price or more • Staff and physicians: no free gifts, no non-scientific literature, no materials, no equipment, no money, no support for in-service education or events or research, from companies of products that fall within the scope of the Code • Substitutes stored so not to be seen by clients • Written info for clients respect the Code

21. Compliance with the International Code of Marketing of Breastmilk Substitutes Canadian interpretation: • No marketing materials, samplings, coupons, or gift packs given to pregnant women or mothers of babies less than 6 months • No direct/indirect contact between pregnant women or mothers of babies less than 6 months and employees of companies of products that fall within the scope of the Code

22. To come... • Detailed indicators for each integrated step • Appendices for: * Content of the policy and its summary * Educational content for staff and physicians * Educational content for mothers: prenatal, postnatal (hospital and community) * Criteria for a good latch, effectiveness of breastfeeding,... * Medical indications for supplementing before 6 months of age * Cue-based feeding,... * Etc, as needed......

23. Scientific evidences for the Ten Steps and the Code • Updated as serious research results are added to the original evidences • For industrialized countries, meeting with WHO every two years • For the Ten Steps and for the Code (WHO; AHRQ-USA; UK-NHS R&D HTA Programme; PAHO;Paneuropean breastfeeding plan)

24. Remaining challenges in Canada In • Breastfeeding rates • Breastfeeding exclusive rates • Respect of the TenSteps • Respect of the Code

25. Remaining challenges in Canada Breastfeeding rates and exclusivity rates: • Low for developed and rich country • Higher in the west, lower in the east • Exclusivity is not respected until 6 months

26. The Canadian maternity experience(2009) • Initiation within one hour • from birth: 90,3% • Total bf at 6 months: • 53,9% • Exclusive bf at 6months: • 24,4% • Total bf at 12 months: • 15,9 % Picture by Dumas, with permission

27. Remaining challenges in Canada Ten Steps: • Still exception to have an institutional bf policy • Bf education is not uniform and not at basic initial professional training, so no common messages to parents • Future parents not all informed with facts • No immediate and uninterrupted skin-to-skin from birth for all vaginally and cesarean delivered babies • No common messages to help mothers initiate and maintain lactation • Many supplements given without medical indications • Not all mothers with their babies on a 24hour basis • Schedules and timing still used to feed infants • Pacifiers are more than common • Lack of support after discharge or after few days postpartum

28. Remaining challenges in Canada Lack of respect of the Code that Canada has endorsed since 1981 Publicity on false claims Health professionals endorsing breastmilk substitutes Scanned by Dumas from Canadian journals for general population

29. But BFI is a long road towards excellence in clinical practices

30. Comments? Questions? Pictures by Dumas, with permission

31. How to reach me Louise Dumas, RN, MSN, PhD Retired professor-researcher Associated with the Department of Nursing Sciences Université du Québec en Outaouais Guest researcher Department of Women and Child Health Karolinska Institutet, Stockholm louise.dumas@uqo.ca