The Global Criteria for Baby Friendly Hospitals in Australia

The Global Criteria for Baby Friendly Hospitals in Australia Booklet 1 Standards for Implementation of the Ten Steps to Successful Breastfeeding with Appendices Baby Friendly Health Initiative, Australia Australian College of Midwives, 2009

1 Have a written breastfeeding policy that is routinely communicated to all health care staff The facility has a written breastfeeding and infant feeding policy that addresses the principles and practices that enable implementation of each of the Ten Steps to Successful Breastfeeding. If the full policy is summarised for display, the summary covers the key points in the policy and includes a note that the full policy may be viewed on request. The Ten Steps on their own do not meet all the requirements of a BFHI policy and are also incomplete as a summary of the policy. The policy is supported by clinical protocols. Review of the clinical protocols shows that they are evidence-based, reflect contemporary breastfeeding practices and are consistent with BFHI standards. All staff caring for mothers and infants and/or young children are aware of the facility s breastfeeding and infant feeding policy and protocols. Staff are able to locate and refer to them. The facility protects breastfeeding by adhering to the relevant provisions of the WHO International Code of Marketing of Breast-milk Substitutes and subsequent WHA resolutions. The policy: prohibits all promotion of artificial feeding and materials which promote the use of infant formula, feeding bottles and teats does not permit the facility to receive free or subsidised (low cost) products within the scope of the Code does not permit the distribution of samples and supplies of infant formula to parents addresses restrictions on access to the facility and staff by representatives from companies which distribute or market products within the scope of the Code prohibits direct or indirect contact of these representatives with pregnant women or mothers and their families does not allow the facility to accept gifts, non scientific literature, materials or equipment, money, or support for in-service infant-feeding-related education or events from these companies ensures that instruction on preparation and feeding of infant formula is given individually and only to parents who need to use it; there is no group instruction supports careful scrutiny at the institutional level of any research which involves mothers and babies, to identify potential implications on infant feeding or interference with the full implementation of the policy. The facility s policy and practices enable and support staff to continue breastfeeding after returning to work. The relevant Divisional Nursing Director (or Director of Nursing) is able to confirm implementation of the policy in relation to the above points. The policy is accessible to mothers and their families, and a summary is visibly posted in each area of the facility which potentially serves pregnant women, mothers, infants and/or young children. These areas include the antenatal clinic; antenatal care areas; birthing suite and birthing centres; maternity wards and rooms; all infant care areas including nurseries, Special Care and NICU; areas through which mothers and/or babies may be admitted (e.g. emergency service); and areas in which they may be cared for after admission (e.g. paediatric ward). 2

continues... The policy summary is available and displayed in the language(s) most commonly understood by mothers who use the facility s maternity services 1. The staff who care for mothers and infants and/or young children are aware of the facility s breastfeeding and infant feeding policy, are able to locate the full policy and know where the policy summary is displayed in the area where they work. The policy and protocols are reviewed and updated at least every 3 years. 1 Language(s) most commonly understood means each language used by 10% or more of mothers who use the facility s maternity services. 3

2 Train all health care staff in the skills necessary to implement this policy All staff who have contact with pregnant women, mothers, babies, and/or young children (in the care of the facility) have received orientation to and education on the breastfeeding and infant feeding policy and the skills necessary to implement the policy. Staff have also been educated on providing support for non-breastfeeding mothers. Staff required to meet this criterion are divided into three groups: Group 1: Staff who assist, or provide education to mothers, in relation to breastfeeding Group 2: Staff who may provide breastfeeding advice but do not assist mothers with breastfeeding Group 3: Staff who have contact with pregnant women and mothers but do not give assistance and do not provide advice as part of their role Group 1: at least 80% of the staff members can: confirm that they have received the required education or, if they have been working in the maternity service less than six months, received orientation on the policy and their role in implementing it answer five out of the six questions on breastfeeding management correctly state three policies or procedures that help promote breastfeeding in a maternity facility describe two issues that should be discussed with a pregnant woman or mother if she indicates that she is considering feeding her baby with infant formula. Groups 2 and 3: at least 70% of the staff members can: confirm that they have received the required education or, if they have been in the maternity service less than six months, received orientation to the policy state one reason why breastfeeding is important state 3 practices that are used in the maternity services to support breastfeeding describe two issues that should be discussed with a pregnant woman or mother if she indicates that she is considering feeding her baby with infant formula (Group 2 only). A copy of the curricula or course outlines for each Group is made available to the assessors. For Groups 1 and 2, this must include education in: the policy and implementation of the Ten Steps to Successful Breastfeeding the facility s protocols and information on breastfeeding and lactation management in a Baby Friendly facility, with a focus on using hands-off techniques and empowering the mother the Acceptable Medical Reasons for the Use of Breastmilk Substitutes (see Appendix 2) the facility s and health workers responsibilities under the International Code of Marketing of Breast-milk Substitutes and subsequent WHA resolutions. how to provide optimal support for mothers who are not breastfeeding, including information on: the risks and benefits of all feeding options how to assist the mother to make a fully informed and appropriate choice suitable to her circumstances 4

continues how to teach mothers who are not breastfeeding safe and hygienic preparation and storage of infant formula and best practices for bottle feeding their babies (Group 1 only) providing this support in ways which minimise the likelihood that breastfeeding mothers will be influenced to use infant formula (Group 1 only) An education schedule for new staff exists and is made available to the assessors. Records of the education indicate that at least 80% of the staff members who have contact with mothers and/or infants have received the required education. Facility records: The facility maintains electronic or hard copy central records which show the number of hours of education completed by each relevant staff member, based on the requirements outlined in this Step. If a component of a Group 1 staff member s education is by Recognition of Prior Learning (RPL), the facility has noted the number of RPL hours (up to 12 maximum) in the record for that individual. Personal Records: All staff must be able to describe how they received the relevant education, including at least 3 hours of supervised clinical experience 2 (Group 1 only). Each Group 1 staff member who is using RPL as a component of their 20 hours education is required to maintain their own personal record of prior learning and to show this to the assessors on request. The record of prior learning should list completed breastfeeding education programs/topics and supervised clinical experience, including the number of hours for each item listed. Staff who can show the assessors evidence of being a currently certified IBCLC, or a current ABA counsellor with a Certificate 4 in Breastfeeding Education, are deemed to have 12 hours RPL and no further RPL documentation is required. continues 2 The supervised clinical experience can be acquired in a single session or cumulatively through supervised experience during normal working day activities. For a definition please see Appendix 1. 5

Required hours of breastfeeding education for each group of staff Requirements to be completed within the 3 year period prior to initial BFHI assessment: Group 1: All staff who assist mothers with breastfeeding, or provide education in relation to breastfeeding, are required to have a minimum of 20 hours including at least 3 hours of supervised clinical experience 3. The content delivery of the 20 hours is flexible: there must be a minimum of 8 hours theoretical education covering the BFHI curriculum (as above); the balance can be further education or supervised clinical experience in the breastfeeding skills relevant to the area of work. Recognition of Prior Leaning (RPL): Group 1 staff are eligible for up to 12 hours RPL as part of the 20- hour requirement. RPL can include theoretical education in breastfeeding and supervised clinical experience in breastfeeding skills. RPL can be granted for breastfeeding education/supervised clinical experience acquired in the 10-year period prior to the BFHI assessment. Group 2: All staff who may provide breastfeeding advice but do not assist mothers with breastfeeding (e.g. most medical staff, some physiotherapists, speech pathologists and dieticians) are required to have a minimum of 2 hours on the facility s policy, relevant skills, the International Code of Marketing of Breastmilk Substitutes and Acceptable Medical Reasons for the Use of Breastmilk Substitutes. Group 3: Staff who have contact with pregnant women and mothers but do not give assistance and do not provide advice as part of their role are required to have orientation on the facility s policy (can answer relevant questions). Note: this includes ward clerks, perioperative and recovery room staff and relevant domestic/hotel staff. New Staff and others who may assist mothers with breastfeeding: New staff (including long-term agency staff) are scheduled for appropriate education as per relevant Group within 6 months of commencing in a maternal-child area; to be completed within 12 months. Relevant BFHI education from another facility (and RPL if applicable) can be credited towards the education required. The following people are made aware of the policy and protocols at commencement of shift/placement/visit: new staff; agency/relieving staff and students who are advising or assisting mothers with breastfeeding mother-to-mother support counsellors or peer counsellors who provide education or visit breastfeeding mothers Requirements for the 3 year period prior to reassessment of the facility: Group 1: Staff who assist mothers with breastfeeding, or provide education in relation to breastfeeding, must have a further 8 hours of relevant breastfeeding education 4 over the 3 years between assessments, including a reorientation on the policy. It is recommended this education is spread over the 3 years. Groups 2 and 3: Staff who have contact with pregnant women and mothers who completed appropriate initial education as above must have a repeat/update of orientation on the policy. Please note: Staff who have commenced work at the facility since the last assessment must meet the initial assessment requirements for their Group (as above), taking into account relevant BFHI education from another facility (and RPL if applicable). 3 See definition of supervised clinical experience in Appendix 1 4 For reaccreditation, continuing education may include: attendance at relevant breastfeeding sessions or workshops; reporting on breastfeeding research and articles; conducting breastfeeding education sessions for staff; repeat or update of original education, etc. Participation in education hours must be documented. 6

3 Inform all pregnant women about the benefits and management of breastfeeding If the facility provides any antenatal service (including booking-in, antenatal clinics, antenatal classes or antenatal inpatient care), breastfeeding education is given to pregnant women using those services. The antenatal service complies with the relevant provisions of the International Code of Marketing of Breast-milk Substitutes and does not promote artificial feeding or products used for this purpose. The Senior Midwife in antenatal services: can confirm that all women are asked about their breastfeeding knowledge and previous experience with baby feeding can confirm that women who did not breastfeed a previous child or had problems with breastfeeding are offered antenatal counselling for breastfeeding can describe how this counselling is facilitated. can outline how breastfeeding education is provided and who provides the education reports on the breastfeeding support groups and services in the local area and describes how mothers are informed about them. A written description of the minimum content of the antenatal education about breastfeeding is made available to the assessors. The antenatal education/discussion covers the following key points: why breastfeeding is important the risks associated with not breastfeeding the importance of early uninterrupted skin-to-skin contact and the first feed why 24-hour rooming-in (staying close to baby) is important why bottle teats and dummies are discouraged while breastfeeding is being established exclusive breastfeeding for the first six months and that breastfeeding continues to be important after six months when other foods are introduced basic breastfeeding and lactation management, including positioning and attachment, feeding cues and frequency of feeding indications that a baby is getting enough milk maintaining and increasing breastmilk supply breastfeeding support groups and services in the community. Written antenatal information about breastfeeding is at the appropriate literacy level and is available in the language(s) most commonly understood by the women who use the facility 5. All educational materials, handouts or sample bags available and/or distributed to antenatal women are made available for the assessors to review and are free of promotion for artificial feeding. At least 70% of pregnant women who are in their third trimester and have attended at least two antenatal visits at the facility or a satellite centre and can confirm that they were asked about their previous knowledge and experience with baby feeding. 5 Language(s) most commonly understood means each language used by 10% or more of women who use the facility s maternity services. 7

continues At least 70% of the same pregnant women confirm that they have been given the opportunity to discuss breastfeeding with a staff member, and they are able to tell the assessor at least two of the following key points: breastfed babies are much healthier than artificially fed babies breastmilk is much better for the baby than infant formula breastfeeding helps mothers and babies bond/feel closer there are health advantages for the mother who is breastfeeding exclusive breastfeeding for 6 months is important, and breastfeeding continues to be important after 6 months when other foods are introduced breastfeeding can continue when working outside the home At least 70% of the same pregnant women are able to describe at least three of the following breastfeeding management topics: importance of early undisturbed skin-to-skin contact how to recognise when the baby is ready for the first breastfeed how to position and attach the baby for breastfeeding why you should breastfeed your baby on demand why 24-hour rooming-in (staying close to baby) is important how frequent feeding helps to assure enough milk how to know if the baby is getting enough milk feeding cues other than crying why bottle teats and dummies are discouraged while breastfeeding is being established At least 70% of the same pregnant women confirm they have not seen displayed in the facility or been given any materials which picture or promote artificial feeding or a proprietary product that is within the scope of the International Code of Marketing of Breast- milk Substitutes (the scope of the Code covers breastmilk substitutes, including infant formula, feeding bottles and teats). At least 70% of the same pregnant women confirm that they have not received from the facility any group education on artificial feeding. 8

4 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 needed The facility has procedures which keep mothers and babies together in skin-to-skin contact for at least an hour after a vaginal or caesarean birth. When the mother plans to breastfeed, the first breastfeed is allowed to occur when the baby is ready. Initiating breastfeeding after a vaginal birth Unless a medically indicated procedure 6 is required, immediate 7 skin-to-skin contact with the mother is facilitated and continues undisturbed 8 until the baby has had the first breastfeed, even if mother and baby have to be transferred. The baby is allowed to follow the normal sequence of innate feeding behaviours and initiates breastfeeding when ready. Staff provides assistance by keeping the mother and baby together and encouraging the mother to recognise and respond to her baby s innate feeding behaviours. Even if the mother is not planning to breastfeed, the skin-to-skin contact is for at least an hour after birth. Initiating breastfeeding after a caesarean birth Skin-to-skin contact between mother and baby should preferably be initiated in theatre suite. Where this is not possible, a mother who has not had a general anaesthetic is in skin-to-skin contact with her baby within 10 minutes of the time she arrives in recovery, unless a medically indicated procedure 1 is required. A mother who has had a general anaesthetic is in skin-to-skin contact within 10 minutes of being able to respond to her baby 9. Once skin-to-skin contact is facilitated, it continues undisturbed until the baby has had the first breastfeed, even if mother and baby have to be transferred. The baby is left undisturbed to follow the normal sequence of innate feeding behaviours and initiates breastfeeding when ready. 6 A medically indicated procedure includes resuscitation or stabilisation procedures for sick and/or preterm infants. Or evidence can be provided that the mother s or baby s condition prevented immediate or undisturbed, continuous skinto-skin contact. There are only a small percentage of babies who require procedures that cannot be carried out with the baby on the mother s abdomen. [Reference: Textbook of Neonatal Resuscitation, 4 th edition, American Academy of Pediatrics, 2000] 7 Immediate (skin-to-skin contact): Although skin-to-skin contact starting immediately after a vaginal birth is optimal, for the purposes of Step 4 there may be up to 5 minutes of separation before continuous skin-to-skin contact starts. As a guide to measuring 5 minutes, the baby should be on the mother s chest in skin-to-skin contact before the second Apgar. 8 Continues undisturbed: Although this step specifies that skin-to-skin contact should continue for at least an hour, it has been shown that most healthy term babies will follow a sequence of pre-feeding behaviours for more than an hour before they are ready to initiate breastfeeding in one study the median was 80 minutes after an un-medicated birth; it may be longer if there have been interventions. If the mother s condition necessitates a toilet break before the baby has breastfed, then the interruption should be as brief as possible, before resuming skin-to-skin contact. Weighing, measuring and bathing the baby are delayed; most required medical procedures can be carried out with the baby on the mother s abdomen. 9 Unless evidence can be provided that the mother s or baby s condition prevents this 9

Staff provide assistance by keeping the mother and baby together, and encouraging the mother to recognise and respond to her baby s innate feeding behaviours. If the mother is not planning to breastfeed, the skin-to-skin contact is for at least an hour. continues The Senior Midwife Birthing Suite 10 and the Senior Midwife Postnatal are able to accurately describe procedures after birth that keep the mother and baby together and encourage the mother to recognise and respond to her baby s innate feeding behaviours. Mothers experience after a vaginal birth: At least 80% of the mothers who had vaginal births, whether or not they planned to breastfeed, confirm that they received the applicable care described above. At least 80% of those who planned to breastfeed confirm the baby stayed with them and they were encouraged to look for signs that indicated their baby was ready for a breastfeed and they were supported to initiate breastfeeding at this time. Mothers experience after a caesarean birth: At least (the applicable percentage 11 ) of mothers who were interviewed who have had Caesarean births, whether or not they planned to breastfeed, confirm that they received the care described above. At least (the same applicable percentage) of those who planned to breastfeed confirm the baby stayed with them and they were encouraged to look for signs that indicated their baby was ready for a breastfeed and they were supported to initiate breastfeeding at this time, unless a medically indicated procedure was required. (Note: mothers may have difficulty estimating time immediately following birth. If time and duration of skin-to skin contact are routinely recorded in the mothers case-notes then this can be used as a cross-check.) Mothers experience with babies in Special Care 12 : At least 66% of mothers report that they have held their babies skin-to-skin, or if not, the staff could provide justifiable reasons why this did not occur. 10 If the facility has a Birth Centre, the Senor Midwife or equivalent from that area should also be interviewed. 11 The applicable percentage is defined as follows: 50% if 4 or fewer mothers who have had a Caesarean birth are interviewed; 70% if 5-7 mothers; 80% if 8 or more mothers. The number of mothers interviewed who have had a vaginal vs. caesarean birth will be determined by the annual percentage of vaginal vs. caesarean births at that facility. 12 For the purpose of interviewing mothers for BFHI assessments, NICU can be included in the definition of special care. 10

5 Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants All postnatal mothers who plan to breastfeed are taught the necessary skills and provided with appropriate support and information to initiate and maintain lactation and to breastfeed their babies. At least 80% of breastfeeding mothers can: report that staff gave further assistance with breastfeeding as required demonstrate correct positioning and attachment describe how to recognise whether the baby is well attached on the breast and breastfeeding effectively describe at least 2 feeding cues (other than crying) report they have been shown how to hand express their breastmilk (if their babies are 24 or more hours old) report they have been provided with written information on how to store and use their expressed breastmilk (if their babies are 24 or more hours old) At least 66% of mothers who are not breastfeeding, and whose babies are more than 24 hours old, confirm: that individual education about artificial feeding has been given they have received supervision in the preparation and giving of feeds can correctly describe at least three of the following: how to clean bottles and teats how to correctly measure a scoop of powdered infant formula how to correctly prepare water for reconstituting powdered infant formula what to do with the remains of an unfinished feed how to test infant formula for correct temperature before feeding to baby risks associated with using a microwave oven to warm bottles of infant formula how to position the baby for bottle feeding signs that indicate the baby is adequately hydrated At least 66% of mothers with babies who are in Special Care 13, and who are breastfeeding or expressing their milk, report that they have been: supported to initiate lactation as soon as possible but within six hours of birth (unless the mother is severely medically compromised) shown how to express their breastmilk and have been provided with assistance as required informed how to maintain lactation by frequent expression of breastmilk informed and provided with written information on how to store, transport and use their expressed breastmilk (if their babies are 24 or more hours old) continues 13 For the purpose of interviewing mothers, NICU can be included in the definition of special care. 11

At least 80% of the staff who were interviewed from Group 1 can: demonstrate correct teaching of both positioning and attachment using a hands-off technique explain how to instruct a mother to recognise if her baby is well attached and feeding effectively can describe an acceptable technique for teaching mothers how to hand express their breasts provide correct information for storage of expressed breastmilk describe how non breastfeeding mothers are assisted to safely prepare infant formula and bottle feed their babies At least 70% of the staff who were interviewed from Group 2 can: state who they can refer mothers to for advice on infant feeding. Women who wish to breastfeed but did not breastfeed a previous child, or had problems with breastfeeding, are provided with appropriate support, assistance and advice from the staff of the facility. If a breastfeeding mother or a breastfed baby/child is admitted to any part of the facility, the support provided is appropriate and facilitates the continuation of breastfeeding. 12

6 Give newborn infants no food or drink other than breastmilk, unless medically indicated Facility data indicates that at least 75% 14 of babies birthed in the most recent 3 months (the most recent 12 months if assessment is for reaccreditation) have been exclusively breastfed or exclusively fed expressed breastmilk from birth to discharge or if not, there is documentation 15 of the Acceptable Medical Reason or documentation 15 of the mother s request for supplementation after informed choice. If any breastfed babies not in Special Care are observed being fed food or drink other than breastmilk, the staff can provide evidence that in at least 80% of cases that there is an Acceptable Medical Reason 16 or it was at the mother s request, having made an informed decision which is documented. If any of the randomly selected breastfeeding mothers report that their breastfed babies have been fed food or drink other than breastmilk, the staff can provide evidence in at least 80% of cases that there is an Acceptable Medical Reason 2 or it was at the mother s request, having made an informed decision which was documented. At least 80% of staff from Groups 1 and 2 can describe: at least three of the Acceptable Medical Reasons 2 for giving food or drink other than breastmilk to breastfeeding babies, two pieces of information that should be discussed with a pregnant woman or mother who is undecided, but considering feeding her baby with infant formula. Materials unsupportive of breastfeeding are not used, displayed or distributed to parents, except informational materials given individually to parents who are artificially feeding. No materials or literature produced by a company which markets or distributes products covered by the scope of the International Code 17 are used, displayed or distributed to parents. No materials or literature which picture or refer to a proprietary product that is within the scope of the Code are used, displayed or distributed. Of the mothers interviewed: at least 80% of those who are breastfeeding confirm they have not seen used or displayed in the facility or been given any materials which picture or promote artificial feeding or a proprietary product within the scope of the Code. 100% of all mothers confirm that they have not been given any free samples or supplies of infant formula, bottles or teats to take home (excluding babies unable to breastfeed and requiring special products because of birth defects or inborn errors of metabolism). Observations and review of materials confirm that: 14 Facilities that are unable to achieve an average 75% exclusive breastfeeding rate over the required period, because of high-risk clientele, should apply to BFHI for special consideration. They will be required to show evidence that their exclusive breastfeeding rate would be at least 75% if the calculation excluded babies who were supplemented for Acceptable Medical Reasons or mother s informed choice, which has been documented. 15 The documentation should explain the reason/s for supplementation and be recorded at the time the decision is made. Consent in advance does not meet this requirement and is considered inappropriate. 16 See Appendix 2 17 See Appendix 3 13

breastmilk substitutes and equipment for artificial feeding in clinical areas are stored discretely and are not openly on display continues retail outlets within the facility do not have promotional materials or displays of products within the scope of the International Code the facility has an adequate space and necessary equipment for giving individual demonstrations of how to prepare formula away from breastfeeding mothers all handouts or sample bags distributed to new parents are free of promotion of artificial feeding or inappropriate breastfeeding practices and do not contain samples of infant formula, foods or drinks or redeemable vouchers for these products. The facility and its staff do not accept or distribute to mothers free or subsidised (low cost) samples or supplies of breastmilk substitutes 18. Breastmilk substitutes, including special formula and other supplies, are purchased by the facility wholesale through a pharmaceutical distributor or by government tender or similar contact, or at a retail outlet, or are brought in by parents for feeding their own infants 18 Facilities using ready-to-use liquid infant formula should be particularly vigilant regarding the purchase price as these products are commonly sold to maternity facilities at a subsidised price; there is potential that the facility may be in breach of the International Code of Marketing of Breast-milk Substitutes. 14

7 Practise rooming-in - allow mothers and infants to remain together 24 hours a day Babies room-in with their mothers 24 hours per day except: when there is a documented medical reason that necessitates separation at mother s request, after having made an informed decision which is documented. The circumstances and duration of all separations lasting more than one hour are documented. At least 80% of mothers whose babies are not in Special Care and whether they are breastfeeding or not: report that since birth, their babies have stayed with them day and night. If any of these mothers report that their babies have been separated from them, the separation meets the standards for this Step, stated in the first paragraph above. can state 2 reasons why full rooming-in (staying close to their babies) is important. If any babies are observed separated from their mothers, in 80% of cases the separation meets the standards for this Step, stated in the first paragraph above. 15

8 Encourage breastfeeding on demand No restrictions are placed on the frequency or length of their babies breastfeeds (assuming baby is breastfeeding effectively); mothers are advised to breastfeed their babies whenever they are hungry or as often as the baby shows readiness to feed; mothers can recognise early feeding cues before crying; mothers know what to do about their breasts if they become uncomfortably full and the baby is asleep or separated from them. At least 80% of mothers who are breastfeeding and whose babies are not in Special Care: report that they have been advised to breastfeed their babies whenever they are hungry or as often as the baby shows readiness to feed (assuming baby is breastfeeding effectively) report that they have been advised that each breastfeed should be as long as baby wants (assuming baby is breastfeeding effectively) can describe what to do about their breasts if they become uncomfortably full and the baby is asleep or separated for a medical reason (if their babies are 24 or more hours old). The Senior Midwife Postnatal reports that mothers are taught to breastfeed their babies in response to early feeding cues, as often as the baby wants. No restrictions are placed breastfeeding. 16

9 Give no artificial teats or dummies to breastfeeding infants The use of artificial teats and dummies is discouraged while breastfeeding is being established; they are not provided by the facility except where there is a legitimate clinical indication, which has been documented. At least 80% of mothers who are breastfeeding and whose babies are not in Special Care: report that, to the best of their knowledge, their babies have not been fed using bottles with artificial teats, or if an artificial teat was used it was at the mother s request, after she had made an informed choice. report that, to the best of their knowledge, their babies have not been provided with a dummy by staff or the facility report that no staff member has suggested that her baby use a dummy while breastfeeding is being established can explain why dummy use is discouraged while breastfeeding is being established. The Senior Midwife Postnatal reports that: breastfed babies are not fed expressed breastmilk or a supplement using artificial teats, unless it is at mother s request, having made an informed decision which is documented dummy use is discouraged by staff while breastfeeding is being established For any breastfed babies not in Special Care, who are observed being fed using an artificial teat, in at least 80% of cases the artificial teat was used at the mother s request, having made an informed decision which was documented. For any breastfed babies not in Special Care, who are observed with a dummy, in at least 80% of cases the dummy is at the mother s initiative, having made an informed decision, and was not provided by the facility. The facility and its staff do not accept or distribute to mothers free or low cost teats, bottles or dummies. A review of records and receipts indicate that these products are purchased by the facility for at least the wholesale price, or by government tender. Alternatively, dummies are brought in by parents for use by their own infants. All educational materials, handouts or sample bags available and/or distributed to new parents are made available for the assessors to review and are free of promotion of bottles, teats or dummies and do not contain samples of, or redeemable vouchers for these products. Dummies, bottles and teats are not displayed in a promotional way in the hospital shop or kiosk and are not included in baby gift packs for sale in the facility. 17

10 Foster the establishment of breastfeeding support and refer mothers on discharge from the facility Ready availability of help with breastfeeding concerns and challenges after discharge from the facility is the key to fulfilment of Step 10. The Person Coordinating the Assessment (or Senior Midwife Maternity) and the Senior Midwife Postnatal 19 : describe the breastfeeding support and follow-up services 20 available in the local area to mothers after they leave inpatient care and can describe how mothers are made aware of these resources report that the staff encourage mothers and their babies to be seen 2-4 days after leaving inpatient care and again in the second week by an appropriately skilled person from the facility or the community who can assess infant feeding and provide any support needed can describe an appropriate referral system to facilitate adequate timing of the follow-up. report that the facility works with and includes the local breastfeeding support groups and services and can state how this is done At least 80% of staff from Group 1 are aware of breastfeeding support groups and other services in their local area and describe at least one way mothers are made aware of them. At least 80% of mothers whose babies are 24 or more hours old, whether or not they are breastfeeding, are aware of how to get help from the facility or how to contact support groups, peer counsellors or other community health services if they have questions about feeding their babies after return home. They can describe at least one mother support group and at least one service in the local community (or provided by the facility) that provides infant feeding support A review of documents and Clinical Pathways indicates that written information is distributed to mothers before discharge regarding how and where mothers can find support and help on infant feeding after returning home. 19 If the facility has a Birth Centre, the Senor Midwife or equivalent from that area should also be interviewed. 20 See definition Breastfeeding support and services (e.g. lactation clinic, telephone support services such as ABA and 24-hour help lines, staff at the facility, maternal and child health services) 18

Appendix 1: Definitions Artificial feeding Infant being fed fully or predominantly with breastmilk substitutes, including infant formula. Babies discharged in the past 3 (12) months For the purposes of BFHI data collection on infant feeding, facilities are not required to include babies who have been in NICU or Special Care for 24 hours or more. Bottle feeding Infant receiving any food or drink, including breastmilk, from a bottle. Breastfeeding at discharge from facility Baby was breastfeeding or breastmilk-fed (including donor milk from a milk bank) at time of discharge. Includes breastfed babies having supplementary feeds. Breastfeeding initiated Baby received at least one feed of colostrum or breastmilk Breastfeeding mothers Mothers who are breastfeeding their babies, or expressing and breastmilk feeding where the baby is not yet able to breastfeed effectively Breastfeeding support and services Mother support includes groups such as the Australian Breastfeeding Association or other mother-tomother/peer groups who have members educated in how to provide breastfeeding support Services includes all services which have staff/members appropriately educated in how to provide breastfeeding support. This could include lactation consultants, breastfeeding clinics, telephone support such as ABA or 24-hour help lines, staff at the maternity facility, maternal and child health services. Breastmilk Substitute Any food being marketed or otherwise represented as a partial or total replacement for breastmilk whether or not it is suitable for that purpose. Caesarean births applicable percentage of mothers interviewed The applicable percentage in Step 4 is defined as follows: 50% if 4 or fewer mothers who have had a Caesarean birth are interviewed; 70% if 5-7 mothers; 80% if 8 or more mothers. Complementary feeding This term is widely used in WHO s Global Strategy for Infant and Young Child Feeding, and other international documents, to indicate the feeding of solid foods. Therefore, for BFHI purposes including data collection, fluid feeds given to breastfed infants are called supplementary feeds. See the definition of supplementary feeding. Discharged from the facility For BFHI hospital assessment purposes, including interviews with mothers, discharged means discharged from the facility s care, to a maximum of 14 days domiciliary care (see definition below). For data collection on infant feeding, women are deemed to be discharged from the facility when they leave inpatient care. Domiciliary Care For BFHI purposes, this definition includes ongoing care provided by the facility s staff in the mother s home, a hotel or similar setting, to a maximum of 14 days. For example, Hospital in the Home, Midwifery in the Home, Extended Midwifery Service or Domiciliary Midwifery Care. Readmissions, outpatient breastfeeding clinics and domiciliary services contracted to other providers are not included. 19

Exclusive breastfeeding from birth to discharge Breastfeeding or breastmilk-fed the baby has had no other liquids or solids with the exception of drops or syrups consisting of vitamins, mineral supplements or medicines. Breastmilk-fed includes mother s expressed milk or donor milk from a milk bank. The exclusive breastfeeding rate is the percentage of total babies discharged, not just the percentage of those who are breastfed or have received breastmilk. Facility For BFHI purposes, facility means the entity which is preparing for accreditation or being assessed. It is usually a hospital but may be another type of facility which provides maternity services. The assessment of a facility includes all areas which may be accessed by pregnant women or mothers who are breastfeeding, or provide care for infants or children who are breastfeeding. One facility may have more than one site. Hands-off Techniques Techniques used to empower mothers by teaching them to correctly position and attach their babies for breastfeeding, without the staff member touching the mother or baby, or doing it for them. It is recognised that individual care takes priority and these techniques are not applicable to every situation. Nursery (Well Baby Nursery) For the purpose of these documents, this includes any area where normal, newborn babies are cared for when separated from their mothers. It includes being cared for at the postnatal ward nursing desk or station, or a Special Care Nursery being used for well babies. Rooming-in From birth, the baby has been allowed to stay with the mother day and night, except for periods of up to one hour for medical procedures. For BFHI purposes, any other separation must be for documented to show that it was for medical reasons or at the mother s request, having made an informed decision. If more than the occasional normal newborn baby is away from its mother for some or all of the night, the facility is not considered to be encouraging or complying with rooming-in. Samples/Supplies For the purpose of these documents, samples/supplies refer to free or subsidised (low cost) products within the scope of the International Code. BFHI facilities may not accept or distribute such samples or supplies. Samples are single or small quantities of a product provided without cost, but not including products purchased by the facility and provided to mothers for immediate use within the facility. Supplies are quantities of a product provided for use over an extended period. Skin-to-skin contact The baby is naked (or wears only a nappy) and is prone on the mother s naked chest with the baby s head between her breasts; mother and baby may then be covered appropriately in a way that does not restrict their interaction or the baby s innate feeding behaviours. Special Care For the purpose of interviewing mothers for BFHI assessments, Neonatal Intensive Care Unit can be included in the definition of Special Care. Supervised Clinical Experience Supervision should be by someone who is experienced and knowledgeable about evidenced based, contemporary breastfeeding practices consistent with BFHI standards. The supervised clinical experience can be acquired in a single session or cumulatively through supervised experience during normal working day activities. It may include observation and or assisting with a particular practice e.g. breast expression, assisting with a breastfeed, discussing breastfeeding with pregnant woman (antenatal clinic or booking-in), facilitation of skin to skin contact at birth and early initiation of breastfeeding, support provided to a non-breastfeeding mother. This definition is based on the WHO 20-hour course: Breastfeeding Promotion and Support in a Baby Friendly Hospital 20

Supplementary feeding A breastfed infant has been given one or more fluid feeds, including infant formula. For the purposes of BFHI data collection and for calculating exclusive breastfeeding rates, feedings of expressed breastmilk are not considered a supplementary feeding. Also see definition of complementary feeding. Supplement rate The percentage of babies who have been given infant formula or other fluids by mouth at least once between birth and discharge from the facility s inpatient care: Acceptable supplement rate: the percentage of babies who were given a supplement where there is a documented Acceptable Medical Reason 21 or there is documentation of the mother s request after informed choice. Other supplement rate: the percentage of babies who were given a supplement without a documented Acceptable Medical Reason or without documentation of the mother s request after informed choice. 21 See Appendix 2 for Acceptable Medical Reasons for Supplementation 21

Appendix 2: Booklet 1: Standards for Implementation Acceptable Medical Reasons for Use of Breastmilk Substitutes World Health Organization 2009 Reproduced by BFHI Australia, Australian College of Midwives, with permission. All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications whether for sale or for non-commercial distribution should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Preface A list of acceptable medical reasons for supplementation was originally developed by WHO and UNICEF as an annex to the Baby-friendly Hospital Initiative (BFHI) package of tools in 1992. WHO and UNICEF agreed to update the list of medical reasons given that new scientific evidence had emerged since 1992, and that the BFHI package of tools was also being updated. The process was led by the departments of Child and Adolescent Health and Development (CAH) and Nutrition for Health and Development (NHD). In 2005, an updated draft list was shared with reviewers of the BFHI materials, and in September 2007 WHO invited a group of experts from a variety of fields and all WHO Regions to participate in a virtual network to review the draft list. The draft list was shared with all the experts who agreed to participate. Subsequent drafts were prepared based on three inter-related processes: a) several rounds of comments made by experts; b) a compilation of current and relevant WHO technical reviews and guidelines (see list of references); and c) comments from other WHO departments (Making Pregnancy Safer, Mental Health and Substance Abuse, and Essential Medicines) in general and for specific issues or queries raised by experts. Technical reviews or guidelines were not available from WHO for a limited number of topics. In those cases, evidence was identified in consultation with the corresponding WHO department or the external experts in the specific area. In particular, the following additional evidence sources were used: The Drugs and Lactation Database (LactMed) hosted by the United States National Library of Medicine, which is a peerreviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed. The National Clinical Guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn, review done by the New South Wales Department of Health, Australia, 2006. The resulting final list was shared with external and internal reviewers for their agreement and is presented in this document. The list of acceptable medical reasons for temporary or long-term use of breast-milk substitutes is made available both as an independent tool for health professionals working with mothers and newborn infants, and as part of the BFHI package. It is expected to be updated by 2012. Acknowledgments This list was developed by the WHO Departments of Child and Adolescent Health and Development and Nutrition for Health and Development, in close collaboration with UNICEF and the WHO Departments of Making Pregnancy Safer, Essential Medicines and Mental Health and Substance Abuse. The following experts provided key contributions for the updated list: Philip Anderson, Colin Binns, Riccardo Davanzo, Ros Escott, Carol Kolar, Ruth Lawrence, Lida Lhotska, Audrey Naylor, Jairo Osorno, Marina Rea, Felicity Savage, María Asunción Silvestre, Tereza Toma, Fernando Vallone, Nancy Wight, Antony Williams and Elizabeta Zisovska. They completed a declaration of interest and none identified a conflicting interest. Introduction Almost all mothers can breastfeed successfully, which includes initiating breastfeeding within the first hour of life, breastfeeding exclusively for the first 6 months and continuing breastfeeding (along with giving appropriate complementary foods) up to 2 years of age or beyond. Exclusive breastfeeding in the first six months of life is particularly beneficial for mothers and infants. 22