Breastfeeding Grand Rounds Series 10 th Anniversary August 3, :30am - 9:30am (EDT) Viewer Call-In. Phone:

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1 Breastfeeding Grand Rounds Series 10 th Anniversary August 3, :30am - 9:30am (EDT) The Baby-friendly Hospital Initiative (BFHI): Yesterday, Today, and Tomorrow Moderator: Mary Applegate, MD, MPH Speakers: Miriam Labbok, MD, MPH Ruth Lawrence, MD Sponsored By School of Public Health, University at Albany NYS Department of Health, Bureau of Women s Health Funded in part by: USDHHS Maternal and Child Health Bureau Viewer Call-In Phone: Fax: Evaluations Please fill out your evaluation and post-test online: Continuing education credits are available. Thank You! University at Albany School of Public Health Continuing Education For more information please contact us or log on to our website. coned@albany.edu Labbok

2 Imagine that Breastfeeding Supports: The world had created a new dream product that would feed and immunize every child on earth It is available everywhere, requires no storage or delivery, and helps mothers to space her births and reduce her risk of cancer, and The world refuses to allow or support its use. - Derived from a speech by Mr. James Grant, Director of UNICEF, Birth Spacing and Fertility Maternal Health and Survival Nutrition Reduced Cancers and Chronic Diseases Oral Rehydration Growth and Development Immunization Logo, Breastfeeding Division, IRH Relative risk of non-breastfed children dying from infectious diseases from two international data sets, when compared to breastfed infants, by age group 6 5 (WHO data) WHO Collaborative Team on the Role of Breastfeeding in the Prevention of Infant Mortality, Lancet 2000;55:451-5 (DHS data) Rutstein S. International Journal of Gyn/Ob. 2005; 89:S7-S24. Nutrition is a Major Correlate of Survival 1. About 13% of deaths of <5 yo. (1.3 million) could be prevented by improved breastfeeding, alone. - LANCET, July WHO DHS DHS WHO <2 mo 2-3 mo 4-5 mo 6-8 mo 9-11 mo mo 2. Each year approximately 56% of child deaths over 6 mos. of age are due to malnutrition. - Pellitier D et al, Stunting, length/height for age, is highly correlated with good nutrition and good health care; exclusive breastfeeding may be a major contributor to linear growth Lactational Amenorrhea Method (LAM) Ask the mother or advise her to ask herself these three questions: 1. Have your menses returned? NO 2. Are you giving supplements or are there long periods without breastfeeding either day or night? NO 3. Is your baby more than six months old? NO There is only a 1-2% chance of pregnancy at this time. YES YES YES 13/1 When the answer to ANY one of these questions becomes YES The mother s chance of pregnancy is increased. For continued protection, and to achieve child spacing, a complementary family planning method needs to be used, and breastfeeding continue. Institute for Reproductive Health, Georgetown, Washington, DC Global Strategies and Agreements 1981: International Code of Marketing of Breast-milk Substitutes, and subsequent resolutions 1990: Convention on the Rights of the Child 1990: Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding 2002: Global Strategy reinforces the importance of BFHI Labbok

3 Global Strategies and Agreements 2002: Nine UN agencies joined in the development and launching of HIV and Infant Feeding - Framework for Priority Action. 2004: UNICEF/WABA Golden Bow Initiative 2005: Innocenti Declaration calls for support for BFHI with urgency BFHI The Baby-friendly Hospital Initiative initiated by WHO/UNICEF following the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding, 1 August 1990 The Declaration called on all governments by the year 1995 to ensure that every facility providing maternity services fully practices all ten of the Ten Steps to Successful Breastfeeding WHO/UNICEF The Ten Steps to Successful Breastfeeding 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 one half-hour of birth. 5. Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants. The Ten Steps to Successful Breastfeeding 6. Give newborn infants no food or drink other than breastmilk, unless medically indicated. 7. Practice rooming-in - that is, 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. BFHI also supports the International Code of Marketing of Breastmilk Substitutes Contact ibfanpg@tm.net.my BFHI BFHI and Baby-friendly are UNICEF internationally registered marks for the process by which governments, or their designees, implement, assign coordination, assess and monitor this activity. Labbok

4 History of BFHI in the USA 1992: BFHI launched US DHHS Grant to HMHB Coalition for Expert Work Group to examine the criteria and assessment process Wellstart, International: criteria and evaluation materials. The U.S. Committee for UNICEF initial support. 1997: Healthy Children Project, Inc.: Baby- Friendly USA - non-profit organization implementing the Baby-Friendly Hospital Initiative in the United States 3 Steps to Becoming Baby-friendly in USA 1. Make a commitment and Apply for a Certificate of Intent Team - self-appraisal tool. Administrative support Submit a Certificate of Intent packet -- self-appraisal tool, letter of intent, annual fee, written breastfeeding policy. Identifies achievements and challenges. Steps to Becoming Baby-friendly 2. The Baby-Friendly Award process: onsite assessment. Intensive two or three day visit. Assessment fee and annual fee When the facility has passed this assessment it receives the designation of being a Baby-Friendly Hospital. 3. The Baby-friendly Designation Awards and Plaques, and Recertification Posters: UNICEF offices, or a local image. Plaques prepared in each country according to specifications Maternity, 1963, 2003 Estate of Pablo Picasso/Artists Rights Society (ARS), New York BabyFriendly USA Guidance Trends in Numbers of Baby-friendly Hospitals, in (000)s, from UNICEF Country Reports Baby-Friendly USA can provide technical support and offers a guidance document Participation in this initiative provides several possible benefits: Quality improvement Cost containment Public relations/marketing Prestige NB: The Innocenti Declaration was signed August 1, 1990, identifying the practice of the Ten Steps in all maternity services as an operational target. BFHI was developed in 1991, piloted in 12 countries, and inaugurated as a global initiative in Labbok

5 Progress on Exclusive Breastfeeding Percent Exclusive Breastfeeding and Percent Increase by Region, 1990 and 2004 UNICEF 1995 Trend analysis based on 60% of countries % +9% -2% +20% +27% +113% +450% S. Asia East/South Africa E. Asia/Pacific Mid East/N Africa SubSaharan Africa West/Central Afric Developing Countrie BABY-FRIENDLY HOSPITAL INITIATIVE Revised, Updated and Expanded for Integrated Care 1991/2 BFHI Guidelines developed Frequent additions of parts without updates 2002 WHO/UNICEF decision to update 2005 Expert review/ field tests completed 2006 Country level initiation expected Maternity, 1963, 2003 Estate of Pablo Picasso/Artists Rights Society (ARS), New York 2006 Revised BFHI materials: Updates and Changes Reorganized Technical and Program Updated, HIV and maternity issues National implementation options conflict of interest sustainability considerations Expansion and integration options New 20 Hour Course Revised computerized assessment and external assessment tools Section 1 Background and Implementation 1.1. Country Level Implementation End of international oversight 1.2. Hospital Level Implementation 1.3. The Global Criteria for BFHI 1.4. The International Code of Marketing 1.5. Baby-Friendly Expansion and Integration: Mainstreaming and Sustainability 1.6. Resources, References and Websites Section 2: Revised / updated Decision-makers (formerly administrator s) Course - ongoing Section 3: Training Course / Powerpoint Slide Set Every staff member will confidently support mothers to succeed with early and exclusive breastfeeding, and that this facility moves towards achieving Baby-Friendly designation. New areas: Maternity care practices HIV New complementary feeding guidance Community System issues Section 4: 4.1 Hospital Self-Appraisal 4.2 Guidelines and Tools for Monitoring what mothers and staff know and do optional modules Section 5: 5.1 Guide for Assessors 5.2 Hospital External Assessment Tool 5.3 Guidelines & Tools for External Reassessment Labbok

6 Avoid: Ethics of BFHI a) compromising standards, and b) conflict of interest concerns when one group has responsibility and/or income from more than one of the following: maintaining BFHI criteria standards providing the required breastfeeding training granting the designation Alternative Models for Achieving Baby-friendly Status In the USA today, there is one NGO offering designation: Baby-friendlyUSA The revised international BFHI materials offer seven models for consideration at the national or state level. New models have checks and balances, calling for oversight by a national authority, as well as a coordinating group and a designating group. Alternative Models for Achieving Baby-friendly Status 1. Legislate and regulate BFHI standards 2. Incorporate BFHI into national health facility credentialing board procedures. 3. Professional organization includes BFHI in its mandate. Alternative Models for Achieving Baby-friendly Status 4. NGO applies to the National Authority for the right to coordinate the designation process or to serve as a designating committee. 5. Facilities assess each other and help each other to achieve designation status. Alternative Models for Achieving Baby-friendly Status 6. One professional organisation or other NGO, with active oversight of the National Authority, to take responsibility for coordination and/or designation. 7. Not ideal: UNICEF country offices may assist for a very limited period of time until the National Authority and coordinating and designating groups are established. New Materials at New BFHI materials, Accessing posters and plaques specifications Related information Found at unicef.org/nutrition/index_24850.html Labbok

7 New York State Efforts have been made to support the Ten Steps in all hospitals, whether or not designated Baby-friendly Standards set and monitored at the State level could be part of a BFHI approach Case studies of three efforts Best Practices for Breastfeeding Promotion in the Hospital Setting New York State s response to UNICEF s Baby-friendly principles Hospital Code 1980 s NYS Hospital Code breastfeeding amendments Lactation coordinator No routine test bottles or anti-lactation drugs No formula samples for breastfeeding mothers Hospital Surveys Surveyed hospital breastfeeding practices 1995 and twice since Wide variation among hospitals Developed Best Practices Score Correlates with breastfeeding initiation rates Feedback to Hospital CEOs Best Practices Score Hospital s own Regional and statewide comparisons General encouragement to adopt guidelines Highlighted specific problem areas Anecdotally effective (updated 2004) Visible support for breastfeeding Encourage breastfeeding on demand Encourage breastfeeding both day & night Written policy allowing 24-hour rooming-in Labbok

8 No routine orders for anti-lactation drugs No water, glucose water, or formula given to breastfed babies except in special circumstances No formula company materials pens, pamphlets, videos, mugs, other gifts No formula discharge packs given to mothers of breastfed babies No contracts with formula companies requiring the hospital to provide mothers with formula and/or formula company gifts. No pacifiers used with breastfed babies Designated Lactation Coordinator in place, preferable IBCLC First breastfeeding in delivery or recovery room No test bottle given Breastfeeding assessed and documented on every shift Additional information on breastfeeding given to all breastfeeding mothers No timing of breastfeeding sessions All breastfeeding women taught about key breastfeeding topics Breast milk/breastfeeding encouraged and supported in NICU Hospital has good source of breastfeeding information for mothers Breastfeeding instruction sheet provided at time of discharge Support provided to breastfeeding infants and mothers hospitalized after initial delivery stay Labbok

9 Hospital Practices Breast pumps, breaks, and advice/ consultation provided for breastfeeding staff Mothers supported at discharge with at least two follow-up services Arrange for home visit and/or telephone contact with all breastfeeding mothers Positive changes over time Breastfeeding for NICU babies Support for breastfeeding staff members Ongoing causes for concern Lactation consultant role at risk Supplement use routine in some hospitals Formula company influence Follow-up after discharge Baby-friendly NYS? Primary focus: promoting adoption of Best Practices by all hospitals Only ONE hospital with Baby-friendly designation Letter last year urged high-performing hospitals to become Baby-friendly too Interest among several others Why do so few hospitals apply to be Baby-friendly? For Small Birth Centers It s simple: only healthy mothers and well babies For Large, Regional Perinatal Centers It is more complex: Special care nursery Neonatal intensive care nursery Large pediatric wards Labbok

10 Hospitals Without Birth Centers Budget Limitations Maternity unit design does not accommodate rooming-in Hospital budgets may not be available for Letter of intent Cost of review Annual cost of maintaining status Viewer Call-In Phone: An obstacle can be the cost of paying for formula in a tertiary center where there are sick mothers, sick babies, and readmitted bottle-fed infants. Fax: Rochester General Hospital For International Updated BFHI Materials: Urban hospital 2,700 births per year Officially Babyfriendly since 2000 Multidisciplinary team approach to breastfeeding support Strong emphasis on exclusive breastfeeding Labbok

11 Bassett Healthcare Healthcare network serving rural area in central New York 650 births per year Midwife-focused birth center Lacation consultants available 24/7 Pragmatic approach to breastfeeding support NYC Health & Hospitals Corp. Comprehensive public health care system Mission: provide care for all New Yorkers, regardless of ability to pay 21,000 births/year Breastfeeding Initiative system-wide Evaluations Please fill out your evaluation and post-test online: Continuing education credits are available. Thank You! Labbok