Addressing Concerns and Misperceptions about SB 402 (De León)
1. Concern: The bill mandates the Baby Friendly Hospital Ten Steps.
SB 402 specifically allows hospitals to use alternative processes that are equivalent to the
“Ten Steps to Successful Breastfeeding” Baby Friendly Hospital Initiative, it does not
mandate Baby Friendly certification.
SEE: SB 402, page 3, line 5: “… or an equivalent process recognized by the State
Department of Public Health.”
While Baby Friendly certification is considered the “gold standard” for quality hospital
breastfeeding support, there are several evidence-based alternatives that hospitals could
adopt:
 In California, the Department of Public Health has developed and endorsed the
California Hospital Model Policies. These can be found online and include a
comprehensive Training and Technical Assistance toolkit.
 Northern California Kaiser Permanente (KP) hospitals have improved breastfeeding rates
by implementing a smaller “bundle” of evidence-based practices without requiring
Baby Friendly certification. The Joint Commission Perinatal Core Measure of Exclusive
Breastfeeding is a key outcome indicator. (In Southern California, all KP hospitals are
pursuing Baby-Friendly certification, and at least 13 of 15 have already achieved it.)
Nationally, KP recently released a comprehensive toolkit for use by any hospitals who
want to improve their breastfeeding support and outcomes.
 The Texas Ten Step Program http://texastenstep.org/ is based on the Baby Friendly Ten
Steps and recognizes “Star Achiever” hospitals that obtain at least 85% of the Ten Steps
and are already designated as Texas Mother-Friendly Worksites.
2. Concern: The bill is premature.
SB 402 sets January 1, 2020 as the deadline for all maternity hospitals in the state to adopt
quality breastfeeding policies and tracking indicators. Most hospitals report that it takes two to
three years to plan and implement the changes necessary to improve breastfeeding support for
new mothers. A six-year timeframe therefore seems very reasonable.
In 2011, Governor Brown signed SB 502, which requires all maternity hospitals to have an
infant-feeding policy that promotes breastfeeding, by early next year (January 1, 2014). Thus,
existing law (SB 502) is a bridge to SB 402. However, having a policy is only the first step in the
process; the law does not require any organizational change. Rather than being premature, SB
402 is extremely well-timed, since it takes advantage of growing breastfeeding policy
momentum and new funding for preventive services in healthcare reform. SB 402 builds on SB
502 by requiring concrete and meaningful policy implementation over the next six years.
3.
Concern: The bill is too costly.
The results of a recent study show that the overall cost of delivering a baby in a Baby Friendly
hospital is not significantly more expensive than in a non-baby friendly hospital.
Training: Objections have been raised about the training and education costs of implementing a
Baby Friendly or equivalent model. There are a variety of ways to train hospital staff over time
instead of all at once, save costs by accounting for previous breastfeeding training, and by using
on-line resources and free or low-cost county and/or community trainers. In many counties
including Los Angeles, First Five Commissions and health foundations have supported training
costs that support breastfeeding policy changes in hospitals. Pooling resources by coordinating
shared trainings between hospitals is another way to cut costs.
Rooming In. Requiring mothers and babies to “room in” does not require the costly
construction of additional rooms and hospital beds. Rooming-in allows the baby’s bassinet to
be next to the mother’s bed, rather than in the nursery. This allows mother and baby the
opportunity to feed when the baby is hungry and provides time for new mothers to bond with
their babies and learn feeding cues. This practice is recommended by all major health
organizations since they improve a variety of health outcomes, regardless of the mother’s
feeding decision. In fact, some experts suggest that rooming in could actually save hospitals
money because of the high costs of operating separate nurseries for healthy infants.
Baby Friendly Fees. Like other accrediting bodies such as The Joint Commission, Baby Friendly
USA charges hospitals a reasonable fee for their services involved with supporting, assessing,
and certifying a hospital using the Ten Step process. However, SB 402 does not require
hospitals to achieve Baby Friendly certification, so these fees are optional.
4.
Concern: This bill is non-essential.
Opponents say that there are already plenty of mandated hospital breastfeeding policy and
data collection requirements and that great progress is being made, so SB 402 is unnecessary.
In fact, aside from the SB 502 mandate for hospitals to have an infant feeding policy in place by
2014, there are no other universal mechanisms to ensure that all California infants get the best
start in life with a chance to breastfeed.

Simply collecting data on an indicator like exclusive breastfeeding does not
automatically mean a hospital will do what it takes to improve outcomes and increase
those rates. It simply means the data is being collected, with no requirement or
expectation for improvement towards a stated target rate. For example, the California
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Department of Public Health has been publishing the exclusive breastfeeding rates of all
California hospitals since 2004, and there are still many hospitals with chronically low
rates – ranging from 6 to 25 per cent! Hospitals that have instituted Baby Friendly
practices have high rates of breastfeeding no matter what populations they serve.
5.

The Joint Commission (TJC), which provides hospital accreditation based on a set of
quality outcome measures, recently added exclusive breastfeeding as a core evaluation
indicator for perinatal care (PC-05) for hospitals. Only hospitals with more than 1,100
births will be required to report the Perinatal Core Measures, starting in January 2014,
while for all other hospitals those measures will remain optional. General hospitals
seeking TJC accreditation do not have to pick perinatal care/breastfeeding as an
evaluation indicator at all, and some California hospitals choose not to do so.

Similarly, federal data collection such as the CDC mPINC hospital survey is useful as a
data collection and comparison mechanism, but it does not require organizational
change or adoption of evidenced-based policies and practices.
Concern: We don’t need a mandate.
Some progress has been made in California. Out of about 260 eligible hospitals, there are now
only 59 certified Baby Friendly Hospitals, with some 40 more in the development phase. But
that leaves about 200 hospitals, some of which are among the lowest performing in the state
in terms of their exclusive breastfeeding rates, making little or no progress. Based on 2011
data, only 27 per cent of California babies were born in Baby-Friendly hospitals. This bill would
allow the other 73 per cent to have the same quality of care.
Since 2005, researchers, public health experts and medical providers have been calling on
California hospitals to improve their infant feeding policies and practices to conform to the
latest evidence and best practice. Dozens of reports have been issued and many conferences
and trainings have been held. In 2011, Surgeon General Regina Benjamin underscored the
urgency of change by issuing a very strong Call to Action to Support Breastfeeding, followed by
First Lady Michelle Obama’s including breastfeeding in her Let’s Move campaign. We all know
what we need to do, and why. Now it is time to act.
Allowing voluntary and incremental evolution of these hospital reforms will exacerbate
already stark health inequities. “Early adopter” hospitals (those already Baby Friendly, for
example) tend to serve a more affluent population, while non- or “late-adopter” institutions
serve more low-income women of color. The longer we wait, the more babies will be born with
poor hospital support for breastfeeding – and suffer poorer health outcomes.
This bill levels the playing field. If California’s children are to have the best chance for good
health from birth, all California hospitals must implement evidence-based breastfeeding
support policies by 2020.
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