THE BABY FRIENDLY
HOSPITAL INITIATIVE
 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)
1989:
The “Ten Steps to Successful
Breastfeeding”
A
joint WHO/UNICEF statement from
“Protecting, Promoting and Supporting
Breastfeeding: The Special Role of
Maternity Services.”
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.
1991:
The launch of the BFHI

The WHO/UNICEF
International Code of
Marketing of Breastmilk Substitutes (and
subsequent relevant
World Health Assembly
resolutions)

The Ten Steps to
Successful
Breastfeeding
In New Zealand:
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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
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.
 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
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
WHO/UNICEF International Code of
Marketing of Breast-milk Substitutes
1.
2.
3.
4.
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
5.
6.
7.
Materials for mothers should be nonpromotional 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
8.
9.
10.
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.
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.
 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.
 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.
THINGS TO DO: For ‘the Code’
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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
 Check
posters comply
 Check
pamphlets given out to
mothers are not advertising anything
found under the scope of the Code
 Check
A/N references and handouts
are also Code compliant
The Ten Steps to Successful
Breastfeeding:
HELPFUL ADVICE
Step One:
Have a written breastfeeding policy
that is routinely communicated to
all health-care staff
100% compliance required for this
step
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
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
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!
Consultation for the Policy:
be seen – good paper trail essential
 Must be wide consultation process!
 Must include consultation with Maori and
any culture represented by >5% of
clientele
 Must
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
 Step
2: Train all health care staff
in skills necessary to implement
this policy.
“ If you think
education is expensive,
try ignorance”
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
 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.
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)
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
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
 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.
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
Suggested education methods:
 Study
days
 On-line education
 Worksheets
 Videos/DVD’s with questionnaires
 Research papers with questionnaire
 Case studies/presentations
 Discussion periods
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
Awareness Level
 This
could include:
 Hospital aides
 Cleaners
 Physiotherapists
 General theatre staff
 Receptionists
 Dietitians
 Anaesthetists
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
 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
Knowledge will:
 Prevent
conflict
 Motivate staff
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
Continued………..
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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
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
 Step
Four: Help mothers
initiate breastfeeding within a
half an hour of birth
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
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
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
 Step
Five: Show mothers how to
breastfeed and how to maintain
lactation, even if they should be
separated from their infants
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
Step Six: ONLY BREASTMILK
UNLESS MEDICALLY INDICATED
In New Zealand we use the words:
‘for sound clinical reasons’
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No promotion of formula
No advertising
No written handouts
Remember
breastfeeding is the
norm!
Formula is a treatment
where breastmilk is
unavailable
Remember:
 BFHI
 The
-
is all about the well baby!
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
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.”
…….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
 Step
Seven: Practice Rooming-in:
Allow mothers and infants to
remain together 24 hours a day
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
Why?
 Reduces
costs
 Requires minimal equipment
 Requires no additional personnel
 Reduces infection
 Helps establish and maintain
breastfeeding
 Facilitates the bonding process
Mothers should be told:
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The importance of rooming-in
for baby/mother and
breastfeeding
Baby’s cues for feeding – crying
is the last cue!!
More breastfeeds
Longer breastfeeding duration
Prevents infection
Safety factors
Safe and unsafe sleep practices
 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%
step
compliance is required for this
 Step
Eight: Encourage
breastfeeding on demand
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
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
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
Step Nine:
Give no artificial teats or
pacifiers (also called dummies
or soothers) to breastfeeding
infants.
Reasons include:
 These
can interfere with the suckling action
the needs of the baby  decreased
stimulation of the breast
 Upsets
 Disempowerment
of the mother

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
Step Ten:
Foster the establishment of
breastfeeding support groups
and refer mothers to them on
discharge from the hospital or
clinic.
“The key to best breastfeeding
practices is continued day-today 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
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
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.
Standards of care for the nonbreastfeeding 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
 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
References:
 The
BFHI Documents for Aotearoa New
Zealand (2011)
 “International Code of Marketing of
Breastmilk Substitutes and Relevant WHA
resolutions” IBFAN 2006