How to Go baby Friendly

The first step to becoming Baby Friendly is to contact the Baby Friendly Hospital Initiative Australia Manger, Kylie Campbell, at the Australian College of Midwives national office in Canberra and your State or Territory BFHI Committee. Kylie will send out an information package which includes a hospital self-assessment questionnaire to help hospitals and units work towards becoming accredited or to determine whether they have all necessary policies and procedures in place and are ready to be assessed.

The hospital or unit then applies for assessment by filling in a Request for Assessment form and completing a Hospital Financial Agreement form. For a copy of these forms please email Kylie Campbell at bfhi@midwives.org.au

The cost of assesment is all inclusive. BFHI will organise travel, accomadation and meals for the assessors. Invoices will be sent to the hospital once the request for assessment and financial agreement are recieved at the National office

Depending on the number of deliveries annually the team may consist of two or three assessors who will spend two days at the hospital. The assessment team is drawn from a varied background, including lactation consultants, general practitioners and midwives. A community representative (usually a breastfeeding counsellor from the Australian Breastfeeding Association) will also be present. All assessors will have undertaken a ten hour workshop on BFHI and have proven expertise with breastfeeding knowledge. Assessors must be able to evaluate the position of babies at the breast, the adequacy of hand expression techniques and the accuracy and completeness of the information given to mothers.The actual assessment includes interviews with senior staff, staff in maternity wards and antenatal areas and with the mothers themselves. It is conducted over one or two days, including interviews with night staff. Senior staff may be identified by name but junior staff members and mothers are identified by number to maintain confidentiality. The assessment team also carries out observations in the wards and antenatal areas on the days of assessment.
The questionnaires are based around the ten steps, and the hospitals must pass all ten steps to be considered baby friendly. To achieve this award the hospital must:

Comply with the WHO Code or the International Code of Marketing of Breastmilk Substitutes. Please see information on what assessors look for when assessing Code compliance here. The full text of the WHO Code is available here

Step 1: Have a written breastfeeding policy that is routinely communicated to all health care staff.
They must have a written policy, a copy of which is provided to the assessment team. It should be available to all staff and mothers and should be visibly posted in all areas which serve mothers and babies.

Step 2: Train all health care staff in skills necessary to implement this policy.
The hospital provides the assessors with documentation covering their education on breastfeeding and % of staff who receive same. Interviews with ten staff cover that a) they have received this education and b) that they can answer 4 out of 5 questions on breastfeeding management. At least 80% should be able to answer correctly.

Step 3: Inform all pregnant women about the benefits and management of breastfeeding.
If the hospital provides an ante natal service the senior midwife should confirm that breastfeeding counselling is given to most pregnant women using these services. A written description of the ante natal education is proved to the assessment team for review. It should cover the importance of exclusive breastfeeding for the first 6 months, the benefits of breastfeeding and basic breastfeeding management. 50% of women interviewed must be able to confirm that the benefits of breastfeeding have been discussed with them and that two of the breastfeeding management topics have been discussed with them
They must also be able to briefly describe these topics. 80% must confirm that no group instruction on the use of infant formula was given to them.

Step 4: Place babies in skin-to-skin contavct with their mothers immediately following birth for at least an hour and encourage mothers to recognize when their babies are ready to breastfeed, offering help if needed..
Of the ten mothers interviewed who had normal vaginal deliveries 80% should report that they were given their babies to hold with skin contact and offered help by a staff member to initiate breastfeeding at this time.
Of the five caesarean deliveries at least three should confirm that within the first hour of being able to respond they were given their babies to hold with skin contact for at least 30 minutes and again offered help by a staff member to initiate breastfeeding.

Step 5: Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
Again we go back to the fifteen mothers interviewed and of these at least 80% should report that they were offered further assistance with breastfeeding. They should have been shown how to, or given information regarding expressing & storing of their breastmilk. Out of the same group of mothers at least 80% of those breastfeeding are able to demonstrate correct positioning and attachment.
We also interview five mothers whose babies are in special care (if applicable) and again 80% of these mothers report that they have been helped to initiate and maintain lactation be frequent expression of breastmilk.
We also interview ten staff members, and 80% must report that they teach mothers positioning and attachment and techniques for manual expression of breastmilk. 80% of these same staff must be able to demonstrate to the assessor's correct teaching of positioning and attachment (how) and an adequate technique for expressing milk.

Step 6: Give newborn infants of breastfeeding mothers no food or drink other than breastmilk, unless medically indicated.
Apart from the mothers we interview, observations are taken on the maternity ward. If babies are fed anything other than breastmilk and the mother reports she is breastfeeding we ask the staff to indicate why this is happening. In at least 80% of the cases there must be an acceptable medical reason, or in the case of formula, at mothers' insistence. There should be no promotion for infant foods or drinks (other than breastmilk) on display or distributed to the mothers or staff.
Again the fifteen mothers interviewed should also report that their babies have received no food or drink other than breastmilk.

Acceptable medical reasons for supplementation:
It is assumed that severely ill babies, babies in need or surgery and extremely low birth weight babies (less than 1000 grams) will be in a special care unit. Their feeding will be individually decided given their particular nutritional requirements and functional capabilities, though breastmilk is recommended whenever possible. These infants in special care are likely to include:

" infants with very low birth weight or who are born pre-term, at less than 1500g or 32 weeks gestational age.
" infants with severe dysmaturity with potentially severe hypoglycaemia, or who require therapy for hypoglycaemia, and who do not improve through increased breastfeeding or by being given breastmilk

Medical reasons (cont) for babies who are well enough to be with their mothers on the maternity ward, there are very few indications for supplements. In order to assess whether a facility is appropriately using other fluids or breastmilk substitutes, any infants receiving additional supplements must have been diagnosed as:

" infants whose mothers have a serious illness which precludes breastfeeding
" infants with inborn errors of metabolism
" critically dehydrated infants
" infants whose mothers are taking medication which is contraindicated when breastfeeding and for which there is no safe alternative

When breastfeeding has to be temporarily delayed or interrupted, mothers should be helped to establish or maintain lactation, by manual or hand-pump, electric pump expression of milk, in preparation for the time when breastfeeding may be begun or resumed.

Step 7: Practice rooming-in - allow mothers and infants to remain together - 24 hours a day.
Of the 15 mothers interviewed 80% should report that since they came to their rooms following delivery (or since they were able to respond in the case of the caesareans) that their infants have stayed with them in the same room day and night, except for periods of up to one hour for hospital procedures or except at the mothers request. We still find that staff offer to take the babies to the nursery to "give the mothers a chance to rest' at night. Of the ten mothers with normal deliveries 80% should report that their babies were separated from them for no longer than one hour before starting rooming in.
With the ward observations all normal postpartum mothers should be observed to have their babies with them or in cots by their bedside.

Step 8: Encourage breastfeeding on demand.
Basically the mothers interviewed should report that there have been no restrictions placed on the frequency or length of their breastfeeding. There should be no difference between the information given to the vaginal or caesarean mums.
The midwife in charge of the maternity ward should also confirm that no restrictions are placed on the frequency or length of breastfeeds.

Step 9: Give no artificial teats or dummies to breastfeeding infants.
Back to those fifteen mums again! At least 80% of them who are breastfeeding report that to the best of their knowledge their infants have not been fed using bottles with teats nor provided dummies by the hospital.
The midwife in charge should report that breastfeeding infants are not fed using artificial teats and that dummy use is discouraged. We acknowledge that this may happen at the mother's insistence. No more than two breastfeeding infants should be observed using teats or dummies during the observations on the ward. The assessors will usually visit the hospital kiosk to see if dummies and/or bottles are being sold there. If this is so they will make a recommendation in their report that this be stopped.

Step 10: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital.
The assessors ask the mums if they are aware of what support is available to them on leaving the hospital. Again 80% should report that their plans for infant feeding after discharge have been explored and that they have been offered information about breastfeeding support groups or programmes, or that the hospital will provide follow up support if needed.
The midwife in charge should be aware of any support groups (ABA) in her area and describe how mothers are referred to them.The assessment team then has to compile all this information from the questionnaires and complete the paperwork. They then make their recommendations and send them back to the project officer, along with a copy of the hospital's breastfeeding policy. Before leaving the hospital they will meet with the staff (usually the ones who have organised the accreditation) and give them an overview of their findings, but not actually informing them whether they have been successful or not. A copy of the completed booklet and assessors recommendations are then sent to two experienced accreditors for review. When this process is complete, the assessment booklet is sent to the hospital along with a copy of the assessor's recommendations. The State committee is notified at this point, and they are responsible for presenting the award to the hospital.