Baby Friendly Initiative

Report to: Chair and members of the Board of Health

Meeting Date: December 7, 2016

Report Number: BH.01.DEC0716.R23

Prepared by: Melissa Potwarka, Manager (A), Family Health Promotion

Approved by: Andrea Roberts, Director, Family Health

Submitted by: Dr. Nicola J. Mercer, MD, MBA, MPH, FRCPC
                           Medical Officer of Health & CEO

Recommendations

It is recommended that the Board of Health:

1. Receive this report for information.

Key Points

• The Baby-Friendly Initiative (BFI) is a global standard that was established in 1991 by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) to improve worldwide breastfeeding initiation and duration rates.
• BFI was established to protect, support and promote the initiation and duration of breastfeeding globally and also to support mothers in making informed choices around infant feeding free from commercial influences.1
• Organizations that receive a BFI designation demonstrate compliance through implementation of standards outlined by the WHO/UNICEF global criteria within the Canadian context. Starting in 2012, the Ministry of Health and Long-Term Care (MOHLTC) requires all public health units achieve and maintain the BFI designation.
• In March 2013, Wellington-Dufferin-Guelph Public Health (WDGPH) received this designation through an extensive external assessment by the Breastfeeding Committee for Canada (BCC).2 Annual reorientation to the BFI Policy is a requirement in maintaining our BFI designation as outlined in the Accountability Indicator Status Report for the MOHLTC.
• BFI designation is reassessed every five years. In order to maintain the BFI designation, WDGPH is required to submit annual self-reporting of breastfeeding statistics, bi-annual BFI status report, and reassessment every five years to BFI Ontario and BCC. The MOHLTC also requires public health units to submit a BFI Status Report, outlining the key activities undertaken for the maintenance of BFI designation. As part of these reporting mechanisms, WDGPH highlights progress on specific activities related to BFI compliance to promote, protect and support breastfeeding, including creating supportive environments, strengthening community actions, public awareness and health education, and evidence-informed practice.
• In addition to ongoing maintenance activities, WDGPH is in the process of preparing for reassessment in early 2018.

Discussion

About the Baby-Friendly Initiative

The BFI is a global standard that was established in 1991 by the WHO and UNICEF to improve worldwide breastfeeding initiation and duration rates. BFI was established to protect, support and promote the initiation and duration of breastfeeding globally and also to support mothers in making informed choices around infant feeding free from commercial influences.1 BFI supports all families in infant feeding, regardless of their feeding choice.

BFI Designation & Reassessment

In March 2013, WDGPH received the BFI designation through an extensive external assessment from the BCC. At the time of designation, WDGPH was one of nine health units in Ontario to achieve this designation.2 WDGPH will be reassessed in 2018. In order to prepare for the upcoming assessment, WDGPH must undertake the specific activities, outlined in Appendix A.
As part of the BFI reassessment, WDGPH must meet the international standards for the WHO/UNICEF global criteria within the Canadian context (Appendix B). Furthermore, a BFI designated facility must be compliant with the “WHO International Code of Marketing of Breast-Milk Substitutes” (Appendix C).2

Breastfeeding Recommendations and Benefits

An essential component of BFI designation is providing information about infant feeding recommendations and the importance of breastfeeding. The WHO and Health Canada recommend that babies should be exclusively breastfed for the first six months of life. Health Canada recommends delaying the introduction of water and solids to six months of age, with the continuation of breastfeeding to two years and beyond.3 Breastfeeding is important for both infants and mothers. For infants, breastfeeding protects against infections, sudden infant death syndrome and chronic health conditions such as diabetes, allergies, asthma and obesity. Furthermore, studies suggest that the significance of breastfeeding can also extend into late childhood and adulthood, providing protection against obesity, type 1 and 2 diabetes, elevated blood pressure and cholesterol, and cancers.4 For mothers, breastfeeding has been found to provide protection against breast cancer, ovarian cancer and osteoporosis.5

WDGPH BFI Policy

The BFI agency policy acknowledges WDGPH as a baby-friendly organization and that breastfeeding is the natural way of providing infants with nutrients they need. This policy is available for review by any member of the public. A user-friendly version has been developed for members of the public, and is posted in public spaces at each office (Appendix D). WDGPH also has a policy to support infant feeding in the workplace, which promotes and supports breastfeeding, and expressing breastmilk on its premises.

The policy supports all individuals with infant feeding on its premises, regardless of their feeding method. The policy outlines the support provided for employees to continue infant feeding upon their return to work. These policies and procedures are reviewed on an annual basis to ensure that they reflect current expectations for the BFI designation. Annual reorientation to the BFI Policy is a requirement in maintaining our BFI designation as outlined in the Accountability Indicator Status Report for the MOHLTC (Attachment E). These policies are sent to staff for their review once a year. They can be also be accessed anytime by staff through a link on the agency intranet site to SharePoint, where all Policies and Procedures are posted.

BFI Accountability and Maintenance

The BCC outlines specific activities for maintaining the BFI designation, which include:
• Annual self-reporting of breastfeeding statistics to BFI Ontario;
• Bi-annual BFI status report submitted to the BCC; and
• Reassessment every five years.2
As of 2012, BFI status became an accountability agreement indicator to the MOHLTC for the Family Health Standard. The MOHLTC requires public health units to submit a BFI Status Report, outlining the key activities undertaken for the maintenance of BFI status.
As part of these reporting mechanisms, WDGPH highlights progress on specific activities, summarized in Table 1.

Table 1: Summary of key activities for ongoing BFI maintenance

Create supportive environments	Strengthen community actions	Public awareness and health education	Evidence-informed practice
• BFI policy re-orientation to staff and Board of Health	• Participation in community breastfeeding networks in Guelph, Wellington & Dufferin	• Promotion of the importance of breastfeeding and infant feeding recommendations, through prenatal education and other social marketing activities, such as World Breastfeeding Week.	• Ongoing infant feeding surveillance
• Annual Policy development and review	• Hospital partnerships and outreach to midwifery practices.	• Postpartum contact and support from public health nurses, through Healthy Babies, Healthy Children, breastfeeding clinics, and KIDS LINE.	• Monitoring infant feeding at post-partum contact
• Professional training/ education for public health nurses working with clients prenatally and postpartum.			•Breastfeeding clinic statistics
• Breastfeeding education days for healthcare providers and others community partners that support breastfeeding mothers

Evidence-Informed Practice

Infant Feeding Survey
WDGPH is currently conducting the Infant Feeding Survey (IFS), which gathers information from mother’s with a newborn baby who consent to participate. This survey was first implemented by WDGPH in 2007, and again in 2012. Once data collection is complete for the 2016 IFS, it will provide WDGPH with longitudinal data that will allow us to monitor infant feeding trends over time. Mothers are asked to complete the survey within four weeks postpartum, and again at 2, 4, 6, 12 and 18 months, depending on their infant feeding practices. The initial survey asks mothers about their pregnancy, early postpartum experiences with their baby, how they are feeding their baby, and the people, services and resources that they have used to support infant feeding. Subsequent surveys ask similar questions as the baby grows and develops. The survey tools were based on the work of a Locally Driven Collaborative Project to standardize infant feeding surveillance across the provinces.
Data collection for the IFS began in February 2016. As of October 2016, the initial survey sample, included 327 mothers, which is approaching the target of 400 mothers. The initial, 2, 4, and 6 month surveys have been implemented, with the 12-month survey due to launch in February 2017.

WDGPH Breastfeeding Triage Data

To supplement the Infant Feeding Survey data, WDGPH assesses infant feeding during the postpartum contact for all mothers who have consented to a phone call from a Public Health Nurse. Table 2 summarizes key components of this assessment. This data provides us with an ongoing account of breastfeeding rates in our community.

Table 2: WDGPH Breastfeeding Triage Data, 2012 to 2015

Year	Current Feeding			Since birth
	Breastfeeding	Formula	Both	Any breastmilk
2012	71%	10%	19%	92%
2013	70%	8%	22%	93%
2014	71%	9%	20%	92%
2015	71%	9%	20%	92%

WDGPH Breastfeeding Clinic Data

WDGPH offers breastfeeding clinics at six locations across WDG, including Guelph, Fergus, Orangeville, Mt. Forest, Palmerston and Shelburne. These clinics are staffed by Public Health Nurses. Table 3 summarizes breastfeeding clinic statistics for 2012 to 2014.

Table 3: WDGPH Breastfeeding Clinic Data, 2012 to 2015

Breastfeeding Clinics	2012	2013	2014	2015
Number of Client Visits	1,670	1,214	1,205	932
Number of Unique Client Visits	675	495	576	535

This data collected by WDGPH is shared with our community partners involved in the breastfeeding collaborations to inform collective service planning that supports breastfeeding in our community.

Conclusion

Moving forward, WDGPH will continue to protect, promote and support breastfeeding through ongoing staff and public education, community collaboration, evidence-informed service planning, and infant feeding surveillance. These activities will support Wellington-Dufferin-Guelph Public Health’s reassessment for the Baby Friendly Initiative designation in 2018.

Ontario Public Health Standards

Reproductive Health Standard

Goal: To enable individuals and families to achieve optimal preconception health, experience a healthy pregnancy, have the healthiest newborn(s) possible, and be prepared for parenthood.
Board of Health Outcomes:

• Expectant parents are aware of the importance of breastfeeding, the mechanics of breastfeeding, and where to obtain assistance with breastfeeding.

Child Health Program Standard

Goal: To enable all children to attain and sustain optimal health and developmental potential.

Societal Outcomes:

• There is an increased rate of exclusive breastfeeding until six months, with continued breastfeeding until 24 months and beyond.

Board of Health Outcomes:

• Breastfeeding women have improved knowledge, skills, and confidence.

Assessment and Surveillance Requirements:

1. The Board of Health shall conduct epidemiological analysis of surveillance data, including monitoring of trends over time, emerging trends, and priority populations in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current), in the areas of: Breastfeeding.

Health Promotion Policy and Development Requirements:

4. The Board of Health shall work with community partners, using a comprehensive health promotion approach, to influence the development and implementation of healthy policies and the creation or enhancement of supportive environments to address: Breastfeeding.
5. The Board of Health shall increase public awareness of: Breastfeeding.
7. The Board of Health shall provide advice and information to link people to community programs and services on the following topics: Breastfeeding.
 

WDGPH Strategic Directions

Strategic Directions

DIRECTION	APPLIES? (YES/NO)
Health Equity: We will provide programs and services that integrate health equity principles to reduce or eliminate health differences between population groups.	NO
Organizational Capacity: We will improve our capacity to effectively deliver public health programs and services.	YES
Service Centred Approach: We are committed to providing excellent service to anyone interacting with Public Health.	YES
Building Healthy Communities: We will work with communities to support the health and well-being of everyone.	YES

Health Equity

Healthy Equity Impact Assessment has not been completed for BFI. Currently, breastfeeding programs and services are offered at a population level with access to all mothers and infants twelve weeks or younger. There are certain populations that experience an increased risk for poor breastfeeding outcomes. These populations include: women who have a lower income and less educational attainment, women who must return to work earlier, are unmarried, lack social support, women who have poor maternal and mental health, and women who smoke during pregnancy.7As WDGPH continues to collaborate to ensure breastfeeding supports are reaching those most at-risk for poor breastfeeding outcomes, targeted programs, services and strategies may be utilized to complement the current universal approach. Programs such as the Healthy Babies, Healthy Children and Pregnancy to Parenting further support these efforts to reach identified priority populations.

Appendices

Appendix A – BFI Reassessment Process and Timelines
Appendix B – WDGPH BFI Reassessment Criteria
Appendix C – Summary of the International Code of Marketing of Breast-Milk Substitutes2
Appendix D – Baby-Friendly Policy: Parents’ Guide
Appendix E – Baby-Friendly Initiative (BFI) Status Report

References

1. BFI integrated 10 steps practice outcome indicators for hospitals and community health services [Internet]. Breastfeeding Committee for Canada; May 2012 [cited 2016 Nov 15]. Available from: http://breastfeedingcanada.ca/documents/2012-05-14_BCC_BFI_Ten_Steps_Int…
2. Wellington-Dufferin-Guelph Board of Health. BOH report – B.H.01.MAY0113.R14 Baby-Friendly Initiative [Internet]. 2013 May 1. [cited 2016 Mar 15] Available from: http://www.wdgpublichealth.ca/sites/default/files/wdgphfiles/BH.01.MAY01… 3. Nutrition for healthy term infants: Recommendations from birth to six months [Internet]. Health Canada; 2014 May 27 [cited 2015 Mar 2]. Available from: http://www.hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/recom/index-eng….
4. Child health guidance document [Internet]. Ministry of Health Promotion; May 2010 [cited 2015 Mar 2].
5. Ten great reasons to breastfeed [Internet]. Public Health Agency of Canada; 2009 [cited 2015 Mar 2]. Available from: http://www.phac-aspc.gc.ca/hp-ps/dca-dea/stages-etapes/childhood-enfance…
6. Wellington-Dufferin-Guelph Board of Health. BOH report – B.H.01.DEC0314.R28 Feeding choices survey [Internet]. 2014 December 3. [cited 2015 Mar 6] Available from: http://www.wdgpublichealth.ca/sites/default/files/wdgphfiles/BH_01_DEC03…
7. Best Start Resource Centre. (2014). Populations with Lower Rates of Breastfeeding: A Summary of Findings. Toronto, Ontario, Canada: author. [cited 2016 Nov 22] Available from: http://www.beststart.org/resources/breastfeeding/BSRC_Breastfeeding_Summ…

APPENDIX A

BFI Reassessment Process and Timelines

BFI Reassessment Steps	WDGPH Timelines
Conduct a BFI Self-Appraisal Completion of a self-appraisal tool that identifies areas requiring more work.	January-March 2017
BFI Pre-Assessment This includes a Document Review and Site Visit.	September 2017
BFI External Assessment Three day process that involves visiting all offices and interviewing staff and clients. If criteria are met a BFI re-designation is obtained.	March 2018
Maintain BFI Status Annual completion of self-monitoring reports. BFI Interim Report every two years. Re-Assessment every five years.	Ongoing

 

APPENDIX B

WDGPH BFI Reassessment Criteria

The assessment criteria reflect the 10 Steps Practice Outcome Indicators for Hospitals and Community Health Services.1

Assessment Criteria
Have a written breastfeeding policy that is routinely communicated to all health care providers and volunteers.
Ensure all health care providers have the knowledge and skills necessary to implement the breastfeeding policy.
Inform pregnant women and their families about the importance and process of breastfeeding.
Place babies in uninterrupted skin-to-skin1 contact with their mothers immediately following birth for at least an hour or until completion of the first feeding or as long as the mother wishes: Encourage mothers to recognize when their babies are ready to feed, offering help as needed.
Assist mothers to breastfeed and maintain lactation should they face challenges including separation from their infants.
Support mothers to exclusively breastfeed for the first six months, unless supplements are medically indicated.
Facilitate 24-hour rooming-in for all mother-infant dyads: mothers and infants remain together.
Encourage baby-led or cue-based breastfeeding. Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods.
Support mothers to feed and care for their breastfeeding babies without the use of artificial teats or pacifiers (dummies or soothers).
Provide a seamless transition between the services provided by the hospital, community health services and peer support programs. Apply principles of Primary Health Care and Population Health3 to support the continuum of care and implement strategies that affect the broad determinants that will improve breastfeeding outcomes.

 

APPENDIX C

Summary of the International Code of Marketing of Breast-Milk Substitutes2

The Code includes these 10 important provisions:

1. No advertising of these products to the public.
2. No free samples to mothers.
3. No promotion of products in health care facilities.
4. No company mothercraft nurses to advise mothers.
5. No gifts or personal samples to health workers.
6. No words or pictures idealizing artificial feeding, including picture of infants, on the labels of the products.
7. Information to health care workers should be scientific and factual.
8. All information on artificial infant feeding, including the labels, should explain the benefits of breastfeeding, and the costs and hazards associated with artificial feeding.
9. Unsuitable products, such as sweetened condensed milk, should not be promoted for babies.
10. All products would be of a high quality and take account of the climatic and storage conditions of the country where they are used.

APPENDIX D

Baby-Friendly Policy: Parents’ Guide (PDF, 2 pages, 1.8 MB)

APPENDIX E

Ministry of Health and Long Term Care (Population and Public Health Division)
Public Health Unit (PHU)
Baby-Friendly Initiative (BFI) Status Report
2016 Mid-year Reporting Form

Health Unit: Wellington Dufferin-Guelph Public Health Date: June 21, 2016
Completed by: Liz Robson Title: Manager, Reproductive Health
Contact phone number: 1-800-265-7293 ext. 4218

Public health units must check off all requirements completed for the time period from January 1,2016 to June 30, 2016 according to the BFI Status Report Reference Guide 2014, posted to the Directory of Networks (DoN) Data Management site and the Family Health Network Collaborative site. A copy of the BFI Status Report submitted to the ministry for BFI baseline, and all reporting periods can be accessed through the PHU folder on the DoN.

Preliminary Work - Requirements

Requirement	Yes/No
Certificate of Intent: Date on Certificate:
PHU has a designated BFI primary contact person Date:
PHU has obtained and communicated endorsement of Medical Officer of Health (MOH)Date:
PHU has obtained copy of the BCC BFI Integrated 10 Steps Practice Outcomes Indicators for Hospital and Community Health Services Tool and initiated self-appraisal Date:
PHU has developed a written plan to achieve BFI designation Date: PHU has developed a plan for staff training Date:
PHU has reviewed their existing data and identified any data needs Date: PHU has identified priorities for the next reporting period – List:

 

Intermediate Work – Requirements

Requirement	Yes/No
Certificate of Participation Date on Certificate:
PHU has identified a multidisciplinary committee Date:
PHU has performed Self-Appraisal Assessment Date:
PHU has developed a written BFI policy Date:
PHU provided Board of Health (BOH), MOH, staff and volunteers initial orientation to the policy and annual reorientation Date:
PHU provided staff education (both direct and indirect providers) Date:
PHU reviewed and updated Prenatal Curriculum Date:
PHU provided written Information Materials including Breastfeeding Matters for women and their families Date:
Endorsement of BOH Date:
PHU developed plan for capturing data Date:
PHU has identified priorities for the next reporting period – List:

Advanced Work – Requirements

Requirement	Yes/No
PHU submitted Documentation Review Contract and Fee to BFI Ontario Date:
PHU submitted Documentation Review Date:
PHU received Documentation Review recommendations Date:
PHU submitted the Pre-Assessment Contract and fee to BFI Ontario Date:
PHU completed data analysis Date: PHU booked Pre-assessment Site Visit Date:
PHU submitted External Assessment Contract and fee to BFI Ontario/ BCC Date:
PHU booked External Site Visit Date:
PHU identified priorities for the next reporting period – List:

BFI Designation – Requirements

Requirement	Yes/No
Original BCC Certificate of BFI Designation Date: OR
Receipt of BCC Certificate for Redesignation Date:

 

Maintenance of BFI Designation - Requirements

Requirement	Yes/No
Date for Next Reassessment - Date:
PHU has designated a BFI primary contact person Date:
PHU submitted annual data review and analysis to BFI Ontario Date:
PHU completed annual reorientation to the BFI Policy Date: March 2016	YES
PHU submitted BFI Ontario Interim Report to BFI Ontario/BCC Date:
PHU has developed a written plan to achieve BFI redesignation Date:
PHU has completed Self-Appraisal Assessment Date:
PHU submitted document review (updated since last designation) Date:
PHU submitted External Assessment Contract and fee to BCC Date:
PHU booked External Site Visit for redesignation Date:
PHU has identified priorities for the next reporting period – List: Continue infant feeding surveillance. WDGPH is in the process of collecting data on a cohort of individuals in the immediate postpartum period and again at 2, 4, 6, 12 and 18 months. Finish development and implementation of “my breastfeeding plan” in the prenatal period in WDG. Resource to be made available to expectant parents through primary care providers, prenatal care providers, at prenatal classes and on the WDGPH website. Work with local businesses to display the international breastfeeding symbol to encourage breastfeeding in public spaces. Continue to chair and support breastfeeding collaboratives in Guelph, Wellington and Dufferin counties Implement new social media outreach mechanisms to connect with parents and parents-to-be about many topics including infant feeding. Fall 2016: World breastfeeding week Fall 2016: Board of Health annual BFI Policy re-orientation Continued participation in committees to support Guelph General Hospital, North Wellington Healthcare Alliance and Headwaters Health Care in working towards BFI designation. Fall 2016: Quintessence breastfeeding challenge (Guelph) Annual data review and analysis submitted to BFI Ontario (July 2016)

 

For Exceptional Circumstances as identified by BCC:

Item	Yes/No
Certificate of Commitment Date:
PHU submits BFI Action Plan to BFI Ontario Date:
PHU has identified priorities for the next reporting period – List: